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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power scooter for treatment of the enrollees osteoarthritis. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power scooter. Auger and colleagues performed a literature review of power wheelchair usage and assigned most of the research designs as very low quality. Power mobility can benefit specific patients. However, in the present case there is a lack of evidence supporting the medical necessity for power mobility. In this case, the patient has impairment of functional mobility but is able to ambulate throughout the household to perform self-care activities with use of a cane to assist movement. A wheelchair has been requested for impairment of functional mobility by his provider. However, a detailed physical therapy evaluation showed the patient is a functional household ambulator with a cane and that he does not want to use a walker which would be the next most advanced assistive device to consider after a cane. After a walker, a manual wheelchair, which the patient is able to propel, would be considered. Finally, last in the hierarchy of assistive devices comes a power mobility device. The physical therapy evaluation found the patient does not have a need for a power mobility device within the home and there is a lack of evidence in his medical records that he needs one for the community. Based on the clinical documentation submitted, a power scooter is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Experimental/Investigational
Decision: Overturned

A 65-year-old male enrollee has requested a wearable cardioverter defibrillator (LifeVest treatment) for treatment of his dilated cardiomyopathy.  Findings:  Two physician reviewers found the wearable cardioverter defibrillator (LifeVest treatment) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. An increase in the risk of sudden cardiac death (SCD), and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with left ventricular dysfunction related to underlying ischemic heart disease. An increase in SCD risk and potential benefit from an ICD has also been demonstrated in patients with a nonischemic cardiomyopathy.  In patients felt to be at high risk of SCD while undergoing a trial of optimal medical therapy, the wearable cardioverter defibrillator (WCD) provides protection against SCD while awaiting improvement in left ventricular (LV) function. In a study of the WCD, 0.7 percent of patients prescribed a WCD for recently diagnosed nonischemic cardiomyopathy required shocks for a ventricular tachyarrhythmia over a mean follow-up period of 57 days (Chung et al). Although this event rate was relatively low, for selected patients with severe but potentially reversible cardiomyopathy, such as tachycardia or myocarditis-associated cardiomyopathy, the WCD may be useful for the prevention of SCD due to ventricular arrhythmias while awaiting improvement in LV function, ICD implantation, or if needed, cardiac transplantation. Therefore, based on the peer-reviewed literature cited above, the clinical documentation provided and this patients risk of SCD, the wearable cardioverter defibrillator was likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for gallbladder and scar tissue removal. Duncan and Riall explain that gallbladder disease is common, and that cholecystectomy is effective in the management of complications such as biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Eckenrode and colleagues found post-cholecystectomy resolution of symptoms in 66% of patients with a positive HIDA scan and 77% of those with a negative HIDA scan, concluding that a HIDA scan with ejection fraction was not useful in patients with typical symptoms of biliary colic and negative ultrasounds, and should not be used to make a decision for cholecystectomy. Tabibian and colleagues report that laparoscopic lysis of abdominal adhesions is associated with improvement in pain, with even partial lysis noted as effective. The authors further note that chronic symptoms related to intra-abdominal adhesions are not uncommon, yet accurate diagnosis can be elusive despite extensive testing, and that laparoscopic lysis of adhesions can provide short and long term therapeutic benefits, confirm or modify the diagnosis, and change management and outcome. In this case, the patient has symptoms potentially consistent with biliary colic or gallbladder-associated pain, and prior laparoscopic findings of possible chronic cholecystitis. In this case, current medical literature supports the possibility that cholecystectomy may result in resolution of the patients abdominal pain while alternatives such as observation or medical therapy would not.  The records document the presence of extensive adhesions, including in the bowel, requiring multiple lysis surgeries in the past, a finding of sigmoid colon adherent to the pelvic wall, and incomplete colonoscopy due to tortuous colon. The patient has undergone an extensive workup for other causes of abdominal pain. In this clinical setting, cholecystectomy and lysis of adhesions are medically indicated to treat the patients left lower quadrant abdominal pain. Therefore, gallbladder and scar tissue removal are medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus.   Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The goal of hepatitis C eradication exists irrespective of fibrosis score.  However, the medical record indicates ongoing illicit drug use. In the context of ideally achieving the medically necessary goal of hepatitis C virus eradication, active recreational use of illicit substance raises concern for non-optimal adherence to hepatitis C treatment.  The literature supports that frequent drug use during treatment was associated with lower sustained virologic response rates than drug abstinence. As such, medical necessity of Harvoni treatment at this time is not demonstrated.  In sum, Harvoni is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested intensive inpatient neurocognitive rehabilitation program (acute rehabilitation) for treatment of her non-ruptured cerebral aneurysm status post craniotomy/surgical clipping with altered mental status.  Findings:  The physician reviewer found that overall, the medical literature does not support acute rehabilitation services for treatment of this patients cognitive deficits. There is a lack of well-designed studies demonstrating the benefit of acute inpatient neurocognitive rehabilitation over outpatient services in patients six months following a brain aneurysm repair. The records indicate that this patient is currently receiving extensive outpatient services in multiple areas. In addition, despite a thorough evaluation, an intensive inpatient neurocognitive rehabilitation program has not been recommended by any of her treating specialists. All told, the requested intensive inpatient neurocognitive rehabilitation program (acute rehabilitation) is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 22-year-old male enrollee has requested sacroiliac joint fusion with graft for treatment of his  sacroiliac joint arthropathy and sacroiliac joint mediated pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other treatment modalities in this patients case.  There is a lack of randomized controlled studies supporting sacroiliac joint fusion for the treatment of chronic low back pain.  The peer-reviewed medical literature consists of small case series reporting very limited safety and efficacy data.  Kibsgard and colleagues studied 50 patients who had undergone sacroiliac joint fusion.  The authors noted that patients treated with this procedure had moderate disability and pain 23 years after surgery.  Per the authors, the group of 50 patients did not differ significantly from the comparable nonsurgical group.  Therefore, the requested sacroiliac joint fusion is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested one-on-one speech therapy and occupational therapy for treatment of his pervasive developmental disorder not otherwise specified (PDD NOS).  Findings:  The physician reviewer found that laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. As studies have shown, plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and speech therapy and occupational therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood. Review of the available peer reviewed medical literature indicates that speech therapy and occupational therapy are medically necessary interventions for the treatment of patients diagnosed with autism.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard. This patient has a history of mast cell activation syndrome and postural orthostatic tachycardia syndrome (POTS). Currently, immunoglobulin replacement therapy is not indicated for the treatment of mast cell disorders. There is a paucity of peer-reviewed medical literature or guidelines supporting an indication for immunoglobulin in this clinical setting. Available studies demonstrating improvement in patient health outcomes with immunoglobulin are small and retrospective. Castells and Butterfield noted that, Acute episodes of mast cell activation require epinephrine, and prolonged episodes may be addressed with corticosteroids. All told, Gammagard is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology 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: The patient has requested authorization and coverage for Euflexxa injections. Findings:  Two physician reviewers found that the ERCI concluded that evidence from eight systematic reviews and six randomized controlled trials suggested that intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. However, the ERCI cautioned that questions remain about the most effective formulations, which patient populations benefit most, and whether hyaluronic acid injections should be combined with other agents to increase effectiveness. There is a lack of detailed documentation of a recent conservative treatment protocol trial and failure. Therefore, the requested Euflexxa injections are not likely to be more beneficial for treatment of the patient medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient mental health services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that upon review of the patients submitted documentation, the patient was not a danger to herself or others; she denied auditory or visual hallucinations; she was cooperative and easily re-directed; and her affect was bright. The records indicate that the patient showed no behavioral problems or agitation. Her level of agitation had improved and she was not hostile. The patient was observed as cooperative with her care, eating and sleeping well. Further indicated was that her medication regimen was stable. She did not experience any adverse events. Thus, the patient no longer met medical necessity criteria for inpatient mental health level of care. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients behavioral health conditions. Therefore, the Health Plans denial should be upheld.  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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of the enrollees prostate cancer. The Health Plan has denied this request indicating that the services at issue were considered investigational. Findings: Two physician reviewers found that IMRT is a tool that providers can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms which helps maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or temporally. Usually, multiple fields are delivered. Radiation therapy after prostatectomy is recommended for patients with high risk features and/or rising PSA in the absence of metastatic disease. A recent study showed that with IMRT, there is no increased toxicity of treating the pelvis versus the prostate bed (Jereczek-Fossa, et al). In addition, the American Urological Association (AUA) and American Society of Radiation Oncology (ASTRO) guidelines indicate that for some anatomical sites such as the prostate, IMRT should be considered the standard of care (Thompson, et al). Consistent with this support, IMRT was the most safe and effective way to treat this patient to close to 70 Gy radiation. The rectum and bladder are in close proximity to the target. In general, the radiation field for the pelvis after prostatectomy is a concave treatment volume around normal structures, for which IMRT is much better suited to conform to, as opposed to conventional conformal radiation. Thus, the IMRT treatments were likely to have been more beneficial for treatment 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 treatment 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for one hour sessions at the frequency of twice per week for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patients speech is at a 13-month receptive level as tested by the In-Plan speech therapist. The etiology of his speech delay is due to a severe developmental delay in his maturation of speech. From the limited available information and his near normal receptive language, the patient is probably intellectually normal.  Regarding the medical necessity of speech and language therapy, it is the medical communitys standard practice to offer speech therapy to a 2-year-old whose speech is at the 3rd percentile for his age. There is a robust medical literature supporting the efficacy of speech therapy in this patient population (Law, et al). In addition to data supporting the efficacy of speech therapy, Goorhuis-Brouwer and Kniff found that cognitive delays did not prevent patients from benefitting from treatment. Further, Buschmann and colleagues concluded that although catch-up development is to be expected in a substantial proportion of late talkers, our data demonstrate that a general wait and see approach is not justified in young patients with language delay. Consistent with the support in the clinical studies and standards of practice, speech therapy is medically indicated for this patient with speech delay. The recommendation is for one hour per week of speech therapy for six months followed by speech re-evaluation. If the patient demonstrates improvement, but still has continues with significant expressive delay, speech therapy should be continued for an additional six months.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Harvoni for 12 weeks.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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 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.