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

The patients parent has requested authorization and coverage for 40 hours per week of 1:1 applied behavioral analysis (ABA) services, eight hours per week of supervision, 0.5 hours per week of parent training, and two total hours for reassessment. The National Autism Center has identified ABA as the most evidence-based treatment for children and adults on the autism spectrum. The Behavior Analyst Certification Board (BACB) has developed guidelines for providers to identify essential components of ABA and clarify authorization requests. Regarding comprehensive treatment, the guidelines state that comprehensive ABA refers to treatment of the multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypy are also typically the focus of treatment. Although there are different types of comprehensive treatment, one example is early intensive behavioral intervention where the overarching goal is to close the gap between the clients level of functioning and that of typically developing peers. These programs tend to range from 30-40 hours of treatment per week. This patients treatment plan included 19 goals, two parent goals, and four problem behaviors that occur at a rate of 33 to 53 times per hour. In addition, the patients scores of the VB-MAPP assessment were low, displaying 12 of a possible 170 points. Furthermore, the patients score on the barriers assessment was below average, indicating the patient displays significant barriers that need to be addressed. ABA can help the patient become more independent and acquire receptive and expressive communication, as well as social, motor, and adaptive skills. The patient meets the criteria for ABA, as the services requested are the most evidence-based treatment for autism, the patient has a diagnosis of autism, and the treatment request falls within the guidelines set by the BACB. All told, the requested 40 hours per week of 1:1 ABA services, eight hours per week of supervision, 0.5 hours per week of parent training, and 2 total hours for reassessment are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, 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 54-year-old male enrollee requested Somatropin growth hormone for medical treatment of the enrollees growth hormone deficiency.  Findings:  Three physician reviewers found that there is no documentation of growth hormone stimulation testing or other clinical information to support a diagnosis of growth hormone deficiency. The records do not include a rationale for growth hormone and there is no documented history of pituitary disease, surgery or radiation or stimulation tests results. Further, the patients IGF-1 levels are normal. Although the patients IGF-1 levels may have been tested as normal while the patient was on growth hormone therapy, additional testing is needed to support an indication for growth hormone therapy. Consistent with these findings, request for Somatropin growth hormone and future treatment is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested a PET scan for an evaluation of her breast cancer. Findings:  Three physician reviewers found that the use of PET scans in oncology cases is rapidly evolving and the indications are constantly changing. A recent position paper by the PET Oncology Registry has advocated the approval of PET scans in the evaluation of virtually all types of tumors.  What remains to be proven, however, is the efficacy of PET scans in the monitoring of patients with previously treated cancer. This particular patient had no physical findings at the time of the PET scan to indicate possible tumor recurrence. There is inadequate evidence to support yearly PET scans in this clinical setting in the absence of other findings indicating possible malignancy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a enrollee has requested reimbursement for the magnetic resonance spectroscopy . Based upon a review of the information provided and the medical literature reviewed, the magnetic resonance spectroscopy was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presented with seizures and was found to have ischemic stroke and a subdural hematoma on CT scan of the brain. The MRI/MRA/MRV of the brain revealed that the patient had an embolic stroke. The providers noted that the patients did not likely have a metabolic disorder. MRS has been shown to be useful in children with seizures when the MRS yielded information that prompted evaluation for metabolic disorders, brain tumor, or cortical dysplasia, or when the MRI was normal. When an MRI/MRA/MRV provide a diagnosis of embolic stroke, there is a lack of data to support the use of MRS as an additional diagnostic modality. Thus, the magnetic resonance spectroscopy  was not likely to have been more beneficial than standard imaging including MRI, MRA and MRV. One reviewer found that the magnetic resonance spectroscopy was likely to have been more beneficial than standard imaging including MRI, MRA and MRV.Final Result: Two of the three reviewers determined that the diagnostic procedure 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:  One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care and is actively practicing.  One Reviewer is board certified in pediatrics and neurology with special qualification in pediatric neurology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vaginal hysterectomy and one day hospital stay. In this case, there is no documentation that any treatment option was discussed outside of a hysterectomy. Given that the patients uterine fibroid is small, and intramural, it may not be related to her heavy cycles. The patients grand multiparous uterus with reduced efficiency may be the cause of her symptoms. Moreover, the patient can be treated with low dose over the counter contraceptive pills to control her cycle. There is no documentation of any absolute or relative contraindication to hormonal control of her cycles. All told, hysterectomy is not considered a first-line treatment option in this clinical setting. Thus, the requested vaginal hysterectomy and one day hospital stay is not supported as 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of Mopath Procedure Level 2 laboratory services. SMA is an autosomal recessive disease characterized by degeneration of spinal cord motor neurons that leads to atrophy of skeletal muscle and overall weakness. The disorder is caused by a mutation in the gene known as the survival motor neuron gene (SMN1), which is responsible for the production of a protein essential to motor neuron function. Because of the severity and relatively high carrier frequency, there has been increasing interest in carrier screening for SMA in the general prenatal population. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for SMA in all women who are considering pregnancy or are currently pregnant. Further, the ACOG also states that ethnic-specific, panethnic, and expanded carrier screening are acceptable strategies for prepregnancy and prenatal carrier screening. Given these findings, screening for SMA in her subsequent pregnancy was medically indicated. Accordingly, the Mopath Procedure Level 2 laboratory service was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Mopath Procedure Level 2 laboratory services was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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 54-year-old female enrollee has requested a continuous passive motion (CPM) machine for treatment of her postoperative shoulder surgery.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested equipment. Based on the documentation provided, the clinical notes do not document whether the patient has failed to increase her range of motion values of the left shoulder postoperatively via supervised therapeutic interventions. CPM use postoperatively for a rotator cuff repair is not medically indicated in the absence of evidence of failure of traditional modalities. Given the lack of documentation of therapeutic interventions, the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Serostim for treatment of the enrollee who has a history of human immunodeficiency virus. Findings:  The physician reviewer found that There is a lack of support for the requested medication in this clinical setting. The current guidelines do not provide specific recommendations for the medication Serostim in treatment of HIV patients who may be experiencing unintentional weight loss. The U.S. Food and Drug Administration approved this medication for the treatment of HIV patients with wasting or cachexia to increase lean body mass and body weight, and improve physical endurance. Concomitant antiretroviral therapy is necessary. In this patients case, depending on the formula used, this patients ideal body weight would be between 152 to 159 pounds. The patients weight was 160 pounds. There is no documentation of recent weight loss.  As such, the Health Plans denial is consistent with best community practice. The requested therapy with Serostim is not indicated based on the available FDA criteria and the patients medical records provided for review. For these reasons, Serostim is not medically necessary for the treatment of this patient. Final Result: The reviewer determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Per colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: 2/3 of 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 a 14-year-old female enrollee has requested the medication Vyvanse for the treatment of the enrollees attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the Health Plan requires that the patient show a documented failure in both the amphetamine class and the methylphenidate class. Although the patient has documented failure on Adderall XR, there is no documented failure of any medication in the methylphenidate class. Vyvanse is not medically indicated for treatment of this patient. The Health Plans requirements are reasonable and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene tests (BRCA and PTEN). Findings:  The physician reviewers found that the standard of care in patients with Ashkenazi descent and breast cancer is to test for BRCA mutations. In this patients case, there is evidence that she meets the criteria for BRCA gene testing. However, there is no evidence in the documentation provided to support testing for PTEN in any patients including Ashkenazi Jewish descent without suggestive features for Cowden syndrome. PTEN mutation analysis (e.g., Cowden syndrome, hamartoma tumor syndrome) may be considered when there is a suspected or known clinical diagnosis of Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome (BRR) or when there is a known family history of a PTEN mutation. The medical record submitted is not indicative of any of these clinical features.  For these reasons, the BRCA gene test performed was likely to have been superior over the standard modalities available for the evaluation of this patient. However, the PTEN gene test performed was not likely to have been more effective than the other options available for evaluation of this patient. Final Result: 2 of 3 reviewers determined that a portion of the services at issue was likely to have been 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: 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hysingla ER for treatment of the enrollees pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient has been taking Norco, which is short acting hydrocodone. The request is for Hysingla ER, a long duration form of this same medication. There is no pharmacologic difference in receptor binding. The medication is released slowly. If the patient did not receive adequate relief from Norco, he is unlikely to receive relief from this formulation. Alternative opiates with different receptor binding are available for this patient. The current medical evidence does not support the requested medication in this clinical setting. All told, Hysingla ER 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 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: Upheld

A 38-year-old female enrollee has requested laparoscopic ureterolysis-CO2 laser procedure for treatment of her obstruction and adhesion of the ureter. Findings: The physician reviewer found that urinary tract involvement through deep infiltrating endometriosis proves to be a rare condition with an incidence range of 0.3-5% and in about 0.08-4.6% of patients with endometriosis. Ureteral endometriosis can be differentiated into extrinsic or intrinsic disease. In the former and most frequent case, the endometriosis is in close proximity to the ureter, whereas in the latter it is characterized by the presence of endometriotic glands and stroma in the ureteral muscularis. The surgical management of deeply infiltrating endometriosis involving the ureter is a complex procedure that requires an accurate balance between the need for complete excision of endometriotic foci and the need to avoid any morbidity associated with radical surgery. Owing to the rarity of ureteral involvement in women with pelvic deeply infiltrating endometriosis, large-scale controlled, randomized studies on its surgical treatment are still lacking, and a clear surgical strategy for dealing with this condition has yet to be identified. Ureterolysis is the surgical technique in which extrinsic disease is removed. With the development of laparoscopic technique, ureterolysis may now be performed using a minimally invasive technique that respects the same principles as traditional urological surgery. Ureterolysis may be used as the initial surgical step for patients with ureteral endometriosis, and may be the only treatment if the extension of ureteral involvement is limited in length and there is no residual ureteral damage or dilatation. In this case, after the patients hospital stay, reports that endometriosis was present adjacent to the ureter. There is no documentation in the operative summary that there were endometrial implants adjacent to the ureter. The identification of the ureter apparently required some dissection in the area of the infundibulopelvic ligament and mid-pelvic sidewall. However, this surgical maneuver as described in the operative summary does not describe a ureterolysis procedure for endometriosis. It was also not a procedure of a complicated nature requiring extensive and advanced technique. Therefore, the procedure at issue was not sufficiently medically intensive to justify a separately billable service.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested octreotide, non-depot form for subcutaneous injection for treatment of his gastroparesis. Findings:  The physician reviewer found that octreotide may worsen gastroparesis.  The current medical literature does not support the use of the requested medication in a patient whose main symptoms revolve around gastroparesis.  There is a lack of support in the medical literature for the use of this medication for patients with mild intestinal pseudo-obstruction.  Rather, octreotide has been used in patients with severe and chronic intestinal pseudo-obstruction.  Mild intestinal pseudo-obstruction, if present, does not justify the use of octreotide in a patient suffering mainly from gastroparesis.  All told, the requested medication is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee requested chemosensitivity and chemoresistance assays for the evaluation of her medical condition.  Findings:  The physician reviewer found thatthe submitted documentation fails to demonstrate the medical necessity of the services at issue.  In vitro drug testing on patients tumor cells prior to applying chemotherapy is difficult to put into clinical use.  An evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004.  The panel concluded that such in vitro drug testing should be limited to clinical trials.  The current medical evidence does not support the services at issue in this patients case.  All told, chemosensitivity and chemoresistance assays were not medically indicated for the evaluation of this patient.