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

The parent of an 11-year-old female enrollee has requested a pediatric neuropsychological evaluation for evaluation of the enrollees learning disability. Findings:  The physician reviewer found that according to InterQual criteria, neuropsychological testing is indicated in cases of acute brain insult/pervasive developmental disorder. Examples include traumatic brain injury, anoxic/hypoxic brain injury, intracranial surgery, neurotoxin exposure, confirmed, cerebrovascular accident, encephalitis/meningitis and pervasive developmental disorder. Other appropriate conditions include brain tumor, cerebral palsy, epilepsy with seizures, hydrocephalus with shunt placement, diagnosed language disorder, multiple sclerosis, genetic condition that affects the brain, structural malformation of the brain and prematurity with birth weight below 1500 g. The history of this patient fails to meet any of these criteria. Further, the American Academy of Child and Adolescent Psychiatry (AACAP) in its practice parameters for attention deficit hyperactivity disorder (ADHD), suggests that neuropsychological testing is only appropriate if psychological testing has been completed and suggests that there may be a significant cognitive disorder. However, ADHD was ruled out in this patient. All told, the requested pediatric neuropsychological evaluation is not medically necessary for evaluation of this patients learning disorder.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-11-month old female has requested 5 hours of applied behavioral analysis (ABA) therapy per week and 1 hour of speech therapy per week for treatment of her delayed language development.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of approximately 30-35%. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Extensive review of the literature including a meta-analysis by Law and colleagues notes the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. According to the authors, children who participate in speech-language therapy show better improvement than those children who receive no treatment. All told, review of the submitted documentation demonstrates that the patient is an appropriate candidate for speech therapy services and speech therapy at a frequency of one hour per week is medically necessary.With regard to the request for ABA therapy, the submitted documentation does not establish the medical necessity of ABA services. ABA is a medically necessary modality for individuals with an autism spectrum disorder who have behavioral problems. Based upon the documentation provided, this patient has not been diagnosed with autism spectrum disorder. Nor do the submitted medical records document any other significant underlying behavior disorder. As such, the patient does not meet clinical indications for ABA therapy. The Health Plans recommendation of evaluation by a psychiatrist is medically reasonable and appropriate in this setting. Accordingly, the requested ABA therapy is not medically necessary for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee requested  intravenous antibiotic Rocephin (ceftriaxone) for treatment of his medical condition.  Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with cerebral vasculitis and a borderline positive Lyme titer. However, there is no documentation showing that cerebrospinal fluid analysis has been performed. In this case, although the patient may have neuroborreliosis, the differential diagnosis of cerebral vasculitis is varied and long. Finally, the medical literature does not support the use of repeat and long courses, beyond four weeks, of antibiotics for the treatment of Lyme disease. Thus, Rocephin was not and is not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested for Protopic 0.1% for treatment of her lichen simplex chronicus. Findings:  The physician reviewer found that the requested medication is effective and safe for the treatment of pruritic vulvar disorders, as noted by Goldstein and colleagues and Weisshaar and colleagues.  Per Aschoff and colleagues, this has been shown to be effective for lichen simplex chronicus, in particular. Given the location of the disease, long-term use of topical steroids is contraindicated due to risks of atrophy on thin skin.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hammertoe correction surgery with intramedullary implants on the second and third toes of the right foot (CPT 28285 x 2). Researchers note that revision procedures of surgery of the lesser toes are challenging. One study likewise notes that the anatomy of the lesser toes is highly complicated and not yet well understood and that the high propensity of the metatarsophalangeal joint to develop hyperextension deformity should be recognized. The author further notes that a successful surgical result requires a well-planned procedure, accurate execution using proper techniques, and meticulous postoperative care and when complications do occur, surgeons should identify culprits so that proper treatment strategies can be successfully executed. In this case, the patient is status post hammertoe correction of her second through fifth toes on the right foot. She reported persistent pain and an examination revealed non-union of the second and third toes on the right foot with valgus deformities. In this clinical setting, given that a revision hammertoe surgery is recommended by the provider to relieve the patients pain and improve function, the requested service is medically indicated. Therefore, hammertoe correction surgery with intramedullary implants on the second and third toes of the right foot (CPT 28285 x 2) is medically necessary for the treatment 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intrauterine insemination (IUI) treatments. Findings:  The physician reviewer found that he decline in fertility with increasing female age is largely due to a rapid decrease in oocyte quantity and quality, with a higher proportion of oocytes displaying genetic abnormalities. Despite significant improvements in medical stimulation and laboratory culturing of embryos, the rate of success with in vitro fertilization (IVF) once female patients reach the age of 44 is negligible. Overall, assisted reproductive technology has a reasonable chance for success until a patient reaches 44 years of age. In addition, the medical literature and guidelines report that IVF has been shown to result in higher success rates than IUI. In this patients case, treatment with IUI is estimated to have a less than 3% probability of resulting in a live birth. For a fertility treatment to be supported as medically necessary, there must be a greater than 5% probability that the approach using the patients eggs will result in a live birth based on clinical history including diagnosis, menopausal status, and outcomes of previous infertility treatment. Based on this patients age and prior failure of 11 IVF cycles and 5 IUI cycles, her odds of conceiving using her own eggs below 3% with IUI. Given the patients history, the odds of aneuploidy are significantly increased while the odds of conceiving are extremely low. For these reasons, the requested IUI treatments are not medically necessary for treatment of this patient. 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility 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 authorization and coverage for an electrophysiological study. Findings:  The physician reviewer found that Al-Khatib and colleagues note that in patients with non-ischemic cardiomyopathy who experience hemodynamically unstable ventricular tachycardia or stable sustained ventricular tachycardia, an implantable cardioverter defibrillator (ICD) is recommended. In this case, the patient has symptoms of near syncope and seizure like activity, and MRI shows evidence of non-ischemic cardiomyopathy and possible infiltrative process. While he currently has no symptoms of heart failure and an EF of 45%, an electrophysiological study would delineate whether the patients ventricular ectopy is hemodynamically significant and stratify his risk for sudden cardiac death. Given that the results of the requested service would aid in the ongoing management of the patients condition, and guide in determining if ventricular tachycardia ablation or ICD placement is appropriate, the requested service is medically indicated. Therefore, an electrophysiological study (CPT code 93653) is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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: Overturned

A 54-year-old female enrollee has requested coverage for Ampyra, 10 mg, one tablet twice per day for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that there is adequate medical literature demonstrating the safety and efficacy of Ampyra for multiple sclerosis (MS) patients. One phase 3, placebo controlled trial conducted by Goodman and colleagues reported class 1 evidence on the positive effects of Ampyra on ambulation in MS patients. In addition, Espejo and Montalban noted that Ampyra is a K+ channel blocker that was recently approved by FDA for the symptomatic treatment of ambulation hardship in MS. This patient has documented MS with associated symptoms including lower extremity and gait impairment. Inadequately treated MS would place the patient at risk of falls, functional limitation, and unnecessary morbidity (Miravalle, et al). Given that Ampyra has been shown to improve function in MS patients, the supervised used of this therapy is medically reasonable and necessary for management of this patients progressive MS.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested a breast magnetic resonance imaging (MRI) scan with computer-aided detection (CAD) for an evaluation of the enrollee who has a history of breast cancer. Findings:  Two physician reviewers found that the use of screening breast MRI in patients with a personal history of breast cancer continues to be the subject of debate. The American Cancer Society does not recommend screening breast MRI for patients with dense breasts or for patients with a personal history of breast cancer. As stated in the article by Saslow and colleagues, The panel also identified several risk subgroups for which the available data are insufficient to recommend either for or against screening. They include women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography. Currently, the accepted guidelines (Porter and colleagues) only recommend screening breast MRI in patients with personal history of breast cancer if they also have history of other high risk factors such as gene mutation. At this time, there is insufficient evidence in the medical literature to support the use of a screening breast MRI in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested tumor necrosis factor (TNF) antagonist testing for treatment of the enrollees Crohns disease.  Two physician reviewers found that the TNF antagonist testing was appropriate to determine whether the patients use of infliximab monotherapy had led to the known potential outcomes of formation of neutralizing antibodies and/or premature clearance of drug from his circulation. The medical literature indicates that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data. Change of dose or drug based on these results improves response to treatment, as measured by clinical response. The study by Hoekman and colleagues demonstrates that lower infliximab troughs are associated with elevated markers of mucosal inflammation in children. Antibody measurements can also be useful in determining whether an additional immunomodulator should be started. In addition, the use of such an adjunctive medication can suppress antibody levels, and is associated with a longer response to infliximab. Moreover, in clinical practice, infliximab levels and antibodies allow the provider practitioner to adjust or change biologic therapy with some objective determinants. Therefore, the TNF antagonist testing 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 testing at issue 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:  One reviewer is board certified in gastroenterology with sub-specialty certification in pediatric gastroenterology and is actively practicing. Two reviewers are board certified in pediatric gastroenterology and are 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

The patient has requested authorization and coverage for referral to a hematologist. Researchers discussed the European League Against Rheumatism (EULAR) 2019 update on the recommendations for management of patients with systemic lupus erythematosus (SLE). Per the authors, Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion. Based on these guidelines, this patients records do not support an indication for referral to a hematologist. There is no report of a significant hematological abnormality or other hematology issue requiring the training and expertise of a hematologist. Therefore, the requested referral to a  hematologist is not medically necessary for eval and treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nivolumab (Opdivo) injections and Foundation One genetic testing for treatment of the enrollees metastatic breast cancer. Findings:  Two physician reviewers found that as noted in the medical literature, Foundation One testing is an assay that explores the mutations or gene over-expressions of an individual patients cancer cell to help guide providers to the most specific treatment for that cancer. However, there is a lack of convincing evidence that the assay adds to decision making ability beyond standard testing. There are a variety of non-randomized trials exploring the value of molecular profiling that have as been unconvincing of the value of this approach. One randomized trial did not demonstrate value of the assay in selecting therapy. A recent report also raised doubts about the use of these assays. Thus, the use of the Foundation One assay is not supported for use in this patients evaluation and treatment. With regard to the requested Opdivo, which is one of a new class of drugs, the checkpoint inhibitors, which act by unblocking the patients native T cells so that they may attack the cancer. There is data that these therapies are effective in certain cancers, such as lung cancer, melanoma, and bladder cancer. However, there is a lack of data of its usefulness in breast cancer. All told, the requested Opdivo injections and Foundation One genetic testing are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: The 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: Upheld

A 68-year-old male enrollee has requested for a bilateral L4-5 single level facet denervation for treatment of his lumbar pain. Findings:  The physician reviewer found that Gallagher and colleagues compared radiofrequency facet denervation with sham intervention. Patients with pain suggestive for facet joint pain received a diagnostic block with local anesthetic in and around the involved joints. Inclusion into the trial was based on a pain reduction or equivocal reaction within 12 hours after local anesthetic. The authors found a significant difference in pain scores in the treatment group versus the sham group. Van Kleef and colleagues selected 31 out of 100 patients with low back pain based on history, examination and one diagnostic block. Specifically, lidocaine was injected slowly at each target, and patients were instructed to score the effect of their pain on a four-step Likert scale 30 minutes after the blocks were administered. Those patients who had at least 50% pain relief were eligible to enter the study. There were significant pain reductions noted in the radiofrequency group compared to the control group at three, six and twelve months. Van Wijk and colleagues selected patients for study based on an intra-articular injection of 0.25 to 0.5 ml lidocaine 2%. If patients had at least 50% pain reduction on a standard visual analog scale (VAS) applied after 30 minutes, they were included in the trial. The combined outcome measure and VAS showed no difference between radiofrequency and sham, although significant VAS improvement occurred in both groups. A common requirement in all three studies was that only patients with documented improvement following a test injection with local anesthetic were deemed suitable candidates for radiofrequency treatment.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Prolia injections. The enrollee has a history of osteoporosis and gastroesophageal reflux disease. A bone density study showed the enrollees bone mineral density had declined. The enrollees endocrinologist recommended increased dosages of vitamin D and calcium supplements, and recommended the enrollee begin anti-resorptive therapy. The endocrinologist reported the enrollee is not a candidate for oral therapy due to her history of gastroesophageal reflux disease. The enrollee describes anxiety regarding intravenous infusion and the enrollee does not want Reclast. The enrollees spouse reports the enrollees vein swells, turns red and itches, for a duration of 15 to 30 minutes, when the enrollee receives infusions; even with saline infusions. A professional society recommends that clinicians offer treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis. The authors also indicate there is insufficient evidence to determine the comparative effectiveness or superiority of one medication over another, within the same class or among classes, for the prevention of fractures. Network meta-analyses demonstrate that, overall, there are no statistically significant differences among the medications. Medical records report this enrollee has a history of depression and anxiety. The notes also report she is fearful of medical treatment. Since there is no difference in effectiveness, the choice of therapy would depend upon the persons compliance with the regimen. If the enrollee refuses intravenous administration, then the use of Prolia, which is administered subcutaneously, becomes the clinical choice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.