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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for subcutaneous implantable cardioverter defibrillator. Based upon current guidelines from the American College of Cardiology, implantable cardioverter defibrillator therapy is appropriate for patients with hypertrophic cardiomyopathy who have significant risk factors for sudden cardiac death. The patient has a history of unexplained syncope and hypotension with exercise as well as a family history of sudden cardiac death and hypertrophic cardiomyopathy. The subcutaneous implantable cardioverter defibrillator device has now been evaluated extensively and showed excellent efficacy in the EFFORTLESS registry with three years of follow-up. The clinical experience to date suggests that the subcutaneous implantable cardioverter defibrillator is appropriate for younger patients under the age of 40 years to avoid the need for intravascular access with its potential for long-term complications. Therefore, the subcutaneous implantable cardioverter defibrillator is likely to be more beneficial for treatment of the patients medical condition than available standard therapy.One reviewer found that subcutaneous implantable cardioverter defibrillator is not likely to be more beneficial for treatment of the patients medical condition than available standard therapy.Final Result: Two of the three reviewers determined that the requested device 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 overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 59-year-old female enrollee has requested a bilateral mastopexy for the treatment of her intertrigo. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the requested procedure is reconstructive in nature. The documentation does not support the existence of an abnormal structure of the body caused by congenital defect, infection, trauma, tumor or disease. While the patient does have sagging breast tissue, the excess tissue is not so great that it constitutes an abnormal structure of the body. Thus, the requested procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning general concepts of medical necessity, there is no documentation in the submitted records of office visits for intertrigo or monitoring of progress of any treatment of such. Although Diprolene is listed as one of the patients medications, there is no statement concerning what this medication was prescribed for or what the patients response was to the medication. Nor is there photographic documentation of irritation of the inframammary fold skin. All told, the submitted evidence does not demonstrate the medical necessity of the proposed bilateral mastopexy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested a neuroplasty of the right medial plantar nerve for treatment of her complex regional pain syndrome.  Findings:  Two physician reviewers found that the medical records note medial ankle/foot pain of several years duration. The patient has been diagnosed with complex regional pain syndrome.  The nomenclature, pathophysiology, and treatment modalities of complex regional pain syndrome are controversial. At this time, there is a lack of specific, scientifically valid treatments for the management of complex regional pain syndrome.  Research into the mechanisms of complex regional pain syndrome has called into question long-held presumptions about the key role of sympathetic dysfunction in the syndrome. The numerous modalities of treatment range from sympathetic ganglion blocks, intravenous regional blocks, administration of a multitude of pharmacologic agents and behavioral interventions, to surgical sympathectomy. Minimally invasive neuroplasty for managing complex regional pain syndrome is a modality in its developmental stages.  Thus, the superior efficacy of the requested neuroplasty of the right medial plantar nerve has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.).  Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of function in older children with autism spectrum disorders, with the use of intensive ABA therapy (Sallows, et al.) The goals for older children are often to identify and remediate particular deficits, such as non-compliance with this patient. The requested duration of therapy is medically reasonable and appropriate for this patient based upon his documented deficits. Thus, it is medically necessary that this patient receive at least six months of ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested a laparoscopic gastric bypass procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 49.8 and significant comorbid conditions, the patient is likely to meet nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient should not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. However, the National Institute of Health guidelines also indicate that gastric bypass surgery should only be considered for for well-informed and motivated patients with acceptable operative risks. This patient would appear to meet criteria for consideration of weight loss surgery, but she has not yet obtained medical, surgical, nutritional or psychological clearance for the procedure. A TSH level to document that there are no treatable metabolic causes for her obesity is also recommended.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair (heavy duty power chair) to perform one or more mobility-related ADLs or instrumental ADLs in or out of the home, including access to the community. In this case, the patient has multiple chronic health conditions, including a need for supplemental oxygen, and has been using a powered mobility device for several years. As such, it is not expected that the patient would be able to accomplish instrumental ADLs in the community using a manual wheelchair or by ambulating. However, the records note that the patient already has a power wheelchair. There are no indications that his current power wheelchair does not meet his mobility-related needs. Therefore, a power wheelchair (heavy duty power chair) is not medically necessary for this patient to perform one or more mobility-related ADLs or instrumental ADLs in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 32-year-old female enrollee has requested an MRI with dye for evaluation of her status post C2 fracture. Findings:  The physician reviewer found that although the records of the trauma are complete, very little history is given as to how the patient did post-treatment and whether she has had any ongoing neurologic symptoms. There are no recent plain x-rays that have been performed to look at the bone and vertebral body alignment, per the submitted documentation. As for the dissection, no neurological symptoms other than headaches are reported, and there is no documentation than brain imaging has been requested.  The most important assessment in trauma is stability. The American College of Radiology Appropriateness Criteria state that trauma is an indication for an MRI of the cervical spine up to 12 months post trauma, but indicate that for patients with chronic neck pain and the absence of neurologic signs and symptoms, plain radiographs should be the initial study performed.  Thus, in this patients case, an MRI with dye is not indicated, as the submitted documentation does not demonstrate that plain x-rays have been performed.  In regards to the neck dissection, the requested MRI would not appropriately evaluate the dissection. In this patients case, an MRI with dye is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention.For these reasons, the requested speech therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg (three times daily) for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg (three times daily) for eight 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 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: Overturned

The patient is a 38-year-old woman who injured her knee. She required an anterior cruciate ligament (ACL) reconstruction. Postoperatively it was noted she had stiffness and limited range of motion. A continuous passive motion (CPM) device was prescribed. The patient has requested reimbursement for the device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery.A CPM device is often prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. In this case, the patients provider noted the patients postoperative progress was slow and she was experiencing stiffness. Subsequently, he appropriately prescribed the CPM device to attempt to regain motion and diminish stiffness in conjunction with physical therapy. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for a breast examination. Findings:  The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  But in terms of surveillance in patients who have had breast cancer, studies have demonstrated that when digital breast tomosynthesis was applied in a study, screening sensitivity had improved. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. Moreover, this study indicated that digital breast tomosynthesis avoided unnecessary biopsies. Final Result: The reviewers determined that the service 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: Reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested LINX Reflux Management System for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The gold standard in this clinical setting is Nissen fundoplication. In addition, there is a lack of follow-up studies to assess the long-term safety of LINX Reflux Management System. Although LINX holds future promise for treatment of a select GERD population, the procedure is not considered standard of care for GERD therapy and is not likely to be superior to other available treatment options. For the reasons provided above, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested reimbursement and prospective authorization and coverage for 81.7 hour per month of direct one-on-one applied behavioral analysis (ABA) services, 10.75 hours per month of supervision by a Board Certified Behavior Analyst, and 32.25 hours per month of social skills group for treatment of his son's autism.  Findings: The physician reviewer found that the services at issue were not and are not medically necessary for treatment of the patients medical condition. According to the records submitted for review, the patient has had documented improvement in skill acquisition in all areas, and most goals have been met. The anti-learning behaviors displayed by the patient do not pose a danger to himself or others. The Behavior Analyst Certification Board recommends fading out, not escalation of services when goals are met. Based on the clinical documentation submitted for review, the request for 81.7 hour per month of direct one-on-one ABA services, 10.75 hours per month of supervision by BCBA, and 32.25 hours per month of social skills group provided were not and are not medically necessary in this clinical setting. Final Result: The reviewer determined that the services at issue were not and 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 31-year-old female with dysfunctional dental malocclusion not treatable with orthodontic therapy. She has difficulty masticating a normal diet. The patients oral and maxillofacial surgeon notes posterior dental cross bite and left condylar hyperplasia. He recommends maxillary corticotomy. The patients orthodontist notes malocclusion and the need for surgical intervention for correction. The Health Plan has denied authorization for orthagnathic surgery on the basis it is not medically necessary for treatment of the patients condition.A review of the dental models, photographs, x-rays, cephalometric analysis, reports and recommendations of the patients doctors reveals a dysfunctional dental malocclusion with posterior cross bite secondary to mild maxillary bilateral hyperplasia and mandibular asymmetry. Additionally, it appears the left mandibular condyle is 3-4 mm longer than the right condyle. Furthermore, the patient has mild facial asymmetry with displacement of the mandible to the left. Based on these findings, surgical intervention is necessary to resolve the patients malocclusion. The requested maxillary corticotomy will result in functional dental occlusion and carries less risk and post-operative morbidity than other procedures. Surgical correction of the mandibular asymmetry secondary to condylar hyperplasia is not necessary. The requested procedure is needed to improve function and is not likely to result in cosmetic benefit, as it will not impact the patients facial asymmetry.  Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested removal of lap band with revision to sleeve gastrectomy for treatment of her obesity. Findings:  The physician reviewer found that while this patient continues to present with obesity following a laparoscopic adjustable gastric band procedure in 2009, there is no evidence documenting overt complications of the band. Further, there is no evidence of recent multidisciplinary consultations that would include a dietary evaluation and behavioral evaluation. Revision to sleeve gastrectomy carries increased surgical risks. In addition, there are differences in dietary requirements with the sleeve gastrectomy including the need for supplementation. Further evaluation of this patient is required before it can be determined that she is an appropriate candidate for a revision procedure. As such, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 30 hours per week of ABA services have been established as medically necessary for treatment of the patients autism. In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior and ABA services can be utilized to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism. Therefore, ABA therapy at the frequency of the recommended 30 hours per week is medically necessary for treatment of 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.