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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Ehlers-Danlos Syndrome Next Generation Sequencing (NGS) Panel (CPT 81408). As noted by the treating provider, the patients presentation is consistent with hypermobile Ehlers-Danlos syndrome, or may fit within a hypermobility spectrum disorder. However, there is no molecular testing to confirm these diagnoses. The provider noted facial and skin findings that could be consistent with vascular Ehlers-Danlos syndrome including a thin face with thin, pinched nose, hollow cheeks, and visible veins. Vascular Ehlers-Danlos syndrome has a risk of serious complications. When considering a diagnosis of vascular Ehlers-Danlos syndrome, testing for this via COL3A1 sequencing, deletion, and duplication analysis is essential to confirm or rule out the diagnosis. This patient does not have findings concerning for other forms of Ehlers-Danlos syndrome. Thus, testing for all of the genes included in the Ehlers-Danlos syndrome NGS panel is not warranted. Therefore, the COL3A1 gene sequencing, deletion, and duplication analysis portion of the Ehlers-Danlos Syndrome NGS Panel (CPT code 81408) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the COL3A1 gene sequencing, deletion, and duplication analysis portion of the Ehlers-Danlos Syndrome NGS Panel (CPT code 81408) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in genetics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A sixty-four year-old female who is post-menopausal with a history of breast cancer is requesting authorization for a repeat bone density scan.  The patient was being treated with letrozole.Reviewers Findings:  The reviewing physician found that it is standard of care to perform more frequent bone scans in patients such as this patient who was taking letrozole, a drug known to cause significant loss of bone density.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested nerve block treatment for medical treatment of his bilateral carpal tunnel syndrome.  Findings:  Three physician reviewers found that there is support in the medical literature indicating that steroid injection into the carpal tunnel may be beneficial once conservative treatments have been tried and failed.  In this case, there is a lack of documentation that the patient failed conservative therapies for at least three weeks. There is also a lack of documentation for surgery contraindication to justify the use of median nerve injection. Therefore, the request for nerve block treatment is not clinically indicated and not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested bilateral upper lid blepharoplasty for medical treatment of her bilateral upper dermatochalasis.  Findings:  The physician reviewer found that the patient presents with evidence of droopy eyelids, but without evidence of visual problems such as obstruction on symptomatology or clinical evaluation. The patient does not report visual obstruction. The photograph submitted for review demonstrates a mild condition of dermatochalasis. In addition, the visual field analysis does not show evidence of a clinically significant visual obstruction. Therefore, a functional deficit has not been demonstrated to establish the medical necessity of the requested services. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested bilateral upper lid blepharoplasty is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested an additional 36 sessions of speech therapy for medical treatment of the enrollees autism and delayed receptive language.  Findings:  The physician reviewer found that in this case, it is medically necessary that this patient receive an additional 36 sessions of speech therapy, as he has severe delay in his receptive and expressive communicative skills. Testing of receptive, expressive, and articulation skills noted an overall profound speech delay. The available speech therapy assessments document these delays and also proposed a specific set of five goals including articulation skills and the ability to sit still. However, in a period of 6 months he achieved only one of these five goals; therefore, continued speech therapy is clinically indicated. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested continued partial hospital program (PHP) level of care services for treatment of her bulimia nervosa. Findings:  The physician reviewer found the patient has been receiving comprehensive services. She has made clinical progress in some areas including improved family dynamics as evidenced by the positive therapy session and the ability to take a short hiatus from the program. However, the patient has continued to struggle with emotional dysregulation, anxiety, impulsivity and eating disordered behavior despite psychotherapy and modification to her psychotropic medication regimen. Overall, the patient remains symptomatic with significant impairment due to her psychiatric condition and has not consolidated the treatment gains necessary to succeed in a less restrictive setting. Although efforts should be geared to mobilize this patient to an intensive outpatient program (IOP), discharging her from PHP at this time would most likely result in relapse requiring re-admission to PHP or a higher level of care. Thus, continued partial hospitalization is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monurol three (3) grams once per week. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.  Review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. Researchers studied the long-term administration of fosfomycin for the prevention of recurrent lower urinary tract infections. The results of the study support fosfomycin trometamol as highly effective in the prophylaxis of urinary tract infection recurrences with beneficial effect in the six months of follow-up. In addition, the report by researchers found that fosfomycin is safe and effective for use in patients with complex comorbidities. In this case, the patient has contraindication of several commonly used antibiotics and she is at high risk for complications of infection. For the reasons provided, the request for Monurol three (3) grams once per week is medically necessary for treatment of the patients medical condition. 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 nephrology 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

An enrollee has requested authorization and coverage for Euflexxa injections for the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Under these circumstances, Euflexxa injections for the right knee are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested for hormone replacement implants for treatment of her menopause.   Findings:  Three physician reviewers found that the use of testosterone in surgical postmenopausal women is controversial and there are no good long-term studies of administration of the testosterone by subcutaneous pellet implantation that would justify its use. The last Endocrine Society Task Force for Androgen Therapy in Women recommended against the use of testosterone in general.   There is no supporting medical evidence for the use of pellet implantation for hormone replacement in this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50-100 mg 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that genotype 1a patients who have failed PEG-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50-100 mg for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for esterified estrogens and methyltestosterone (Estratest H.S. tablet 0.625-1.25 mg). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested medication.  There are many options for estrogen only therapy.  There is no current support for the addition of testosterone to hormone replacement for improved symptom management. Therefore, the requested esterified estrogens and methyltestosterone (Estratest H.S. tablet 0.625-1.25 mg) is not medically necessary 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 obstetrics and gynecology 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 60-year-old female enrollee has requested Lyrica for the treatment of her neck and back pain. Findings:  The physician reviewer found that this patient has pain consistent with neuropathic pain due to radiculitis. She is also diagnosed with myositis (a pattern consistent with fibromyalgia). Lyrica reportedly gave good benefit for her global pain symptoms. She had already tried and failed Neurontin (which is a neuropathic pain medication). Lyrica is medically necessary as it has been approved for treatment of fibromyalgia which this patient has a pattern consistent with. In addition, the studies indicate Lyrica is recommended as a first-line treatment for neuropathic pain.
Appeal type: Medical Necessity
Decision: Upheld

ature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral medial branch block injections. Findings:  The physician reviewer found that herapeutic facet injections have not been shown to provide long-term utility. Kwak and colleagues found that intraarticular lumbar facet joint corticosteroid injections were effective, regardless of facet joint osteoarthritis severity. However, the long-term effects of intraarticular lumbar facet joint corticosteroid injections were not evaluated. Thus, further studies are required to overcome these limitations and support the results of the present study. This patient is being treated for low back and neck pain with radiation to the bilateral shoulders and upper extremities, bilateral hips, and bilateral lower extremities. Physical examination revealed that Gaenslens and Faber tests were positive bilaterally. The patients strength was 4/5 in the lower extremity flexors and 3/5 in the lower extremity extensors. The provider also noted decreased tone in the bilateral lower extremities. The provider reported that the patient has undergone previous lumbar medial branch blocks followed by lumbar radiofrequency ablation. However, detailed documentation is not evident regarding any significant, sustained functional improvement, or decrease in pain levels following these procedures to support an indication for additional medial branch blocks. Furthermore, there is plausible evidence of radiculopathy. All told, the requested bilateral medial branch block injections at L2, L3, L4 and L5 levels are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autistic disorder. Findings:  Three physician reviewers found that autism is believed to be a congenital dysfunction of brain circuitry resulting in profound communication defects and lack of social development. Effective interventional therapy involves one-on-one speech therapy as well as occupational therapy.  Autism is a recognized neurological disorder and requires medical therapy. This patients language and sensory deficiencies have been fully documented. The speech and occupational therapies requested for this patient are medically indicated. This should be continued for one year, and the patients progress should be reevaluated at the end of the year to determine progress and the need to continue services.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for Xifaxan 200mg (20 count) for treatment of her diverticulitis and diarrhea. Findings:  The physician reviewer found that the only condition Xifaxan would improve would be bacterial overgrowth, which has not been documented in this case. Xifaxan has not been shown to prevent attacks of diverticulitis.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prometheus Anser IFX test. Findings:  Two physician reviewer found that based on current guidelines, the recommended dose of Remicade is 5 mg/kg given on week 0, 2 and 6, followed by every eight weeks thereafter. The clinical significance of apparent increased immunogenicity on efficacy and infusion reactions in psoriasis patients as compared to patients with other diseases treated with Remicade over the long-term remains unknown. Thus, as the maximal recommended dose is 5 mg/kg, and the consequence of antibody formation is unknown, there was no role for the Anser IFX testing performed on 1/12/16 as the patient was already being treated with the maximal recommended dose. Final Result: Two reviewers determined that the testing at issue was 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: All three physician reviewers 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the intensive care burn unit services at Bothin Burn Center provided. Findings:  The physician reviewer found that  Frugoni and colleagues state that the mortality rate in burn patients has declined significantly because of reflective of changes in the care of burn patients, particularly the introduction of early excision and grafting and the use of autograft, cadaveric allograft, and synthetic matrices. For calculation of average length of stay, Taylor and colleagues suggest estimating length of stay by calculating the patients age divided by ten, then subtracted by two, and finally adding TBSA for patients 40 years of age or older. Taylor and colleagues do not report standard deviation for length of stay, limiting its practicality for application to any individual hospitalization. Average length of stay is certainly not a determinant of any individual hospital stay, since all patients differ, and all burns differ in severity, even if they are similar in extent. In this case, the patient is 44-years-old and sustained a deep 10% TBSA burn from falling into a fire pit. The patients estimated length of stay would be 12.4 days as an average length of stay after her initial admission for stabilization. The patient had a 10% TBSA burn that was completely third degree and involved her hand and one digit. The patient was transferred for care after initial resuscitation and stabilization after two days on 9/14/20. She underwent surgical debridement and xenografting the following day on 9/15/20. On 9/21/20, five days later, she underwent debridement and split-thickness skin grafting. She was discharged 9/29/20, eight days later. The Health Plan notes that the patient was stable for discharge and hospital transfer on 9/26/20, which was the fifth postoperative day. The mesh over the skin graft was not removed until 9/25/20, by which time she was ambulating to the bathroom with supervision and using a cane. She was still on pain medication with daily dressing changes. By 9/28/20, she was stable with all staples out. There is no indication in the medical records that burn unit care was medically necessary for an additional day and that she could not be discharged or transferred on 9/28/20. Therefore, intensive care burn unit services at Bothin Burn Center provided on 9/26/20 and 9/27/20 were medically necessary for the treatment of the patients medical condition. However, intensive care burn unit services at Bothin Burn Center provided on 9/28/20 were not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.