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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viibryd for treatment of his major depressive disorder and attention deficit disorder.  The physician reviewer found that this patient has a hypercoagulability syndrome and is at risk for thrombotic rather than hemorrhagic stroke. Plavix and aspirin help reduce that risk and thereby place him at risk for hemorrhagic stroke if his doses are too high. The prescribing information for Viibryd notes that the drug may increase your chance of bleeding or bruising. However, there is a lack of evidence that the bleeding risk that Viibryd poses or any other association with bleeding or stroke is any different from any other antidepressant with serotonergic activity. Song and colleagues reported that Lexapro has more significant decrease in platelet count than venlafaxine, but that bupropion, which boosts dopamine and norepinephrine, does not decrease platelet count. According to these findings, bupropion appears to have the lowest risk for bleeding. All told, the requested Viibryd for management of this patients depression is not supported as medically necessary. 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 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested septoplasty, bilateral inferior turbinate reduction and bilateral inferior turbinate out-fracture for treatment of her severe obstructive sleep apnea. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested procedures. Nasal septoplasty is considered medically necessary when an appropriate and reasonable trial of conservative management such as use of topical nasal corticosteroids has failed. This patient had been on a prior trial of nasal corticosteroids but did not complain of symptomatic nasal obstruction or other findings of recurrent rhinosinusitis. Moreover, surgical reduction of the inferior turbinates with or without fracture has not been proven to have evidence-based results for the improvement of sleep disordered breathing.  For this reason, septoplasty, bilateral inferior turbinate reduction and bilateral inferior turbinate out-fracture are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old female has requested growth hormone therapy (Saizen) for treatment of her precocious puberty.  Findings:  The physician reviewer found that this patient has normal stature and an expected blunting of her growth spurt while on gonadotropin-releasing hormone agonist therapy.  While on gonadotropin-releasing hormone agonist therapy, the patients skeletal maturation has been arrested and has not outpaced her linear growth.  Thus, her adult height prediction has improved from 62.7 inches prior to Lupron treatment to 64 inches while receiving Lupron.  Her height prediction falls within the normal range for an adult female.  The addition of growth hormone to gonadotropin-releasing hormone agonist therapy cannot be routinely recommended for augmentation of height in a patient being treated for central precocious puberty, particularly in a patient who has a normal adult predicted height while on Lupron treatment.  There is a lack of large-scale randomized, controlled trials evaluating the addition of growth hormone therapy to gonadotropin-releasing hormone agonist therapy for central precocious puberty.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee, with secondary progressive multiple sclerosis (MS) with relapses, has requested authorization for intravenous immunoglobin (IVIG) therapy.Findings:  The physician reviewer found that while IVIG has been used for the treatment of MS, in the United States it is generally reserved for treatment of severe exacerbations resulting in significant disability or hospitalizations. Based upon the documentation provided, the patients condition had not reached a level of severity sufficient to warrant the use of IVIG.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female enrollee has requested coverage for speech therapy three times per week and occupational therapy utilizing sensory integration therapy for two hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that while some of the speech and language skills serve the dual purpose of enabling the patient to communicate in both educational and non-educational settings, this does not alter the need for communication skills to function within the community. California Assembly Bill (AB) 88 lists autism spectrum disorder as a diagnosis that must be treated in parity with other medical conditions. The submitted documentation confirms the patients diagnosis of autism. The above-cited literature demonstrates that speech therapy is well-accepted as standard treatment for patients with autism and can provide benefit in terms of language and function.Occupational therapy is a well accepted modality for patients with autism. There is evidence supporting the use of occupational therapy including sensory integration techniques to improve deficits of neurologic and sensory processing. Sensory integration therapy is likely to be an integral tool in helping this patient achieve functional goals.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested authorization and coverage for general dental anesthesia. Findings:  The physician reviewer found that in this patients case, the record demonstrates that she had multiple cavities but the provider could not treat her because the patient was uncooperative. Further documentation indicated that that communication techniques had failed. The patient requires extensive dental work. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients. 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 anesthesiology 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

The parent of an eleven-year-old male enrollee has requested Genotropin for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patients height at the time of application was between the 3rd and 10th percentiles. The workup showed normal growth hormone-dependent IGF-1 and IGFBP-3 levels, while an MRI of the brain showed a normal pituitary. A bone age was 1.5 years delayed. The physicians predicted adult height was 167cm. The patients diagnosis appears to be one of constitutionally delayed adolescence, with a predicted adult height above the limit of the FDA 2003 guidelines for idiopathic short stature. Thus, growth hormone therapy in this instance is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested minimally invasive endoscopic resection of the vestibular schwannoma/acoustic neuroma for treatment of her vestibular schwannoma.  Findings:  The physician reviewer found that this patient has a tumor in the cerebellopontine angle.  The two articles referenced are case series describing the benefits of using the endoscope for the treatment of lesions in this area. Neither of these reports directly compared the risks and benefits of procedures performed with the endoscope versus without the endoscope.  While this may be a useful technology in individual types of cases, the criteria for its use and its efficacy have not been defined or demonstrated.  In an office note on the said date, the provider appropriately documented that although he has been involved in the design of endoscopes, he did not believe that the surgery is made easier with an endoscope as opposed to the microscope.  Furthermore, he cautioned the patient regarding surgeons who might make claims about doing the whole surgery using the endoscope, as such procedures are unlikely to actually occur.  In this patients case, the use of the endoscope for removal of a cerebellopontine angle tumor is not medically necessary.  All told, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested a replacement artificial anal sphincter for treatment of her fecal incontinence. Findings:  Two physician reviewers found that  replacement of the artificial anal sphincter represents one of the few remaining options for preserving or improving this patients fecal continence. In this patients case, a permanent colostomy is the alternative. In most cases, patients with artificial anal sphincters have excellent short-term results, and moderate long-term results, often with the need for re-intervention, as this patient is requesting. As noted by Mellgren, reports have demonstrated excellent results with good functional improvement and a significant improvement in quality of life. The medical literature supports the use of an artificial anal sphincter for end-stage fecal incontinence in selected patients who do not have other treatment options, except for colostomy. Thus, a replacement artificial sphincter is the preferred method of treatment in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested 40 hours per week of skilled nursing care for the treatment of the enrollees autism and Hirschsprungs disease. Findings:  The physician reviewer found that the home health nursing evaluation does not document nursing needs sufficient to justify skilled nursing level of care. The submitted documentation does not indicate the patient is receiving any medications intravenously. In addition, the patient feeds orally and does not require tube feedings. Furthermore, the patients parent has been trained in the care of a button cecostomy. The parents can also monitor the patient for seizures as they have been doing when skilled nursing personnel is not present. All told, the patients needs do not require the level of skill or supervision that accompanies skilled nursing services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter pulmonary valve replacement with a Sapien 3 valve. The patients clinical picture includes complex heart disease with symptoms that are partially attributable to high volume moderate-to-severe pulmonary regurgitation. The patients provider has recommended treatment with transcatheter pulmonary valve replacement with use of a Sapien 3 valve. Chatterjee and colleagues noted that, Transcatheter pulmonary valve implantation is approved for the treatment of dysfunctional right ventricle to pulmonary artery conduits. The authors concluded that of the 1,044 patients who underwent transcatheter pulmonary valve replacement, the success rate of the procedure was 96.2%. As noted in the medical records provided for review, the patients right ventricle outflow tract (RVOT) conduit is more than 16 mm, the present valve is 29 mm, and her pulmonary regurgitation is at least moderate. In addition, the patients right ventricle was enlarged on imaging with low normal function. Correction of the patients pulmonary regurgitation via a transcatheter pulmonary valve should help prevent further right ventricle dysfunction and decrease the recurrence of atrial fibrillation. Moreover, the documentation supports that this patient meets the American Heart Association (AHA) and American College of Cardiology (ACC) criteria for the requested transcatheter pulmonary valve replacement with a Sapien 3 valve (Stout, et al.). Given these findings, the requested transcatheter pulmonary valve replacement with a Sapien 3 valve is medically necessary for 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 subspecialty certifications in cardiovascular disease and adult congenital heart 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested a CT angiography for evaluation of possible coronary artery disease. Findings:  Three physician reviewers found that currently, CT angiography is considered investigational and is not a substitute for cardiac catheterization or nuclear spect imaging. Additionally, the test is not supported by the American Heart Association (AHA) as evidenced by an AHA consensus statement in 2006, which indicated the test was not ready for widespread use. Inherent limitations include sensitivity and specificity, need for a low heart rate, lack of visualization of distal vessels, need to use contrast and radiation exposure. To date, clinical trials are small, and overall, the clinical utility of CT angiography remains unproven.Thus, while the noninvasive nature of CT coronary angiography makes it an attractive option, its exact role in the diagnostic algorithm of coronary artery disease has not yet been defined. Furthermore, a recently published trial (Budoff, et.al)
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services (CPT 00740). Findings:  The physician reviewer found that the monitored anesthesia services were not medically necessary during the patients endoscopy/colonoscopy. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office based setting and without the need of monitored anesthesia care. A systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in colonoscopy concluded that when moderate sedation is utilized, there is a high level of physician and patient satisfaction while providing low risk of serious adverse events with all currently available agents. In an article, the authors noted that not all procedures are well suited for the office with sedation. Unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. Studies noted, Since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts of significant post-procedure discomfort; in appropriate patients, these procedures are well suited to office-based practice. However, in this case, the patient did not present with a significant history that would have required monitored anesthesia care. There was no documentation of comorbid conditions that would have placed this patient at risk for complications requiring the need for monitored anesthesia care. Upon review of the patients medical records, the patient did not meet the criteria for monitored anesthesia care. Therefore, anesthesia services (CPT 00740) provided were not medically necessary for management of this patients pain during a routine endoscopy/colonoscopy. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested bariatric (LapBand) surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 40 and multiple co-morbid conditions. She meets the recommendations set by the National Institutes of Health (NIH) for weight loss surgery. The Swedish obese project study has clearly demonstrated that diet and exercise do not result in sustained weight loss in patients with morbid obesity. This study showed the long-term benefits of weight loss surgery and compared surgical intervention to diet and exercise plans. Furthermore, there is no scientific evidence that pre-operative weight loss results in a better outcome long-term for patients who undergo weight loss surgery. This patient meets the requirements set forth by the NIH for weight loss surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in the right knee (J7325). Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 where everything else has been tried, and the options are limited. In this case, the patient has osteoarthritis and is status post arthroscopy of the right knee. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc-One injection in the right knee (J7325) 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: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested MammaPrint testing for evaluation of her breast cancer.  Findings:  Two physician reviewers found that this patient has an early stage breast cancer with features of hormone receptor (HR) negativity, and negative for HER2. The OncotypeDx assay has been shown to have prognostic value for patients with early stage breast cancer that is hormone receptor positive. In contrast, the MammaPrint assay addresses a different patient population. The MammaPrint test was validated in independent datasets that also included young patients as well as BRCA1 mutation carriers (van de Vijver, et al). This patient has triple negative breast cancer and is a carrier of the BRCA1 mutation. Therefore, the utility of the MammaPrint assay was likely to have been more beneficial in treating her medical condition than any standard alternative.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested growth hormone therapy with Nutropin AQ NuSpin for treatment of the enrollees growth hormone deficiency.  Two physician reviewers found that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient is more than two standard deviations (SD) scores below the corresponding mean height for his age. His original IGF-1 levels were low for his chronologic age. Several studies have demonstrated that growth hormone therapy generally increases height velocity acutely and may increase adult height in children. The United States Food and Drug Administration (FDA) approved growth hormone therapy with the indication for children with current height below -2.25 SD of the mean, in whom the epiphyses are not closed, and whose expected adult height is less than 63 inches (160 cm) for boys and 59 inches (150 cm) for girls. Furthermore, there are limitations of provocative growth hormone testing such as the reliance on arbitrary definitions of what constitutes a subnormal response to stimulation and the limited value in discriminating between normal short children and children with partial growth hormone deficiency. In this clinical setting, the patient fits the criteria for growth hormone deficiency and growth hormone stimulation testing is not indicated. Final Result: Two reviewers determined that the requested medication is 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: One reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. One reviewer is board certified in pediatrics and is actively practicing. One reviewer is board certified in pediatric endocrinology 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.