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

Findings:  The physician reviewer found that The parents of an enrollee have requested reimbursement for Super Food Panel Allergy Testing provided on 6/15/20 by Foundation Labs.Findings: Three out of three physician reviewers found that the Super Food Panel Allergy Testing provided on 6/15/20 by Foundation Labs were not likely to have been more beneficial for the enrollee than any available standard therapy.Bernstein and colleagues state that testing for the most common allergenic foods usually detects most suspected food hypersensitivity, although more tests may be required depending on the clinical situation. Many clinicians test with a limited panel of commonly allergenic foods when food allergy is suspected and there is no clear-cut history of symptoms occurring after exposure to specific foods. The primary tools available to evaluate patients adverse reactions to foods include history (including diet records), physical examination, prick/puncture skin tests, serum tests for food specific IgE antibodies, trial elimination diets, and oral food challenges. The general aims of diagnosis are to determine if food is causing the disorder under evaluation and, if so, to identify specific causal food(s). A proper diagnosis will allow the patient to receive instructions regarding avoidance of problematic food. The current literature and Allergy Practice Parameter Guidelines that address immunoglobin G (IgG) diagnostic testing, which includes IgG food sensitivity and IgG subclass testing, notes that neither of these tests are considered clinically useful, relevant, or a valid method for evaluating for food allergy or food intolerance that may be contributing to an allergic condition. In this case, the medical literature does not support IgG diagnostic testing for the evaluation of this patients food allergy. Therefore, Super Food Panel Allergy Testing provided on 6/15/20 by Foundation Labs was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested for acute inpatient mental health treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that the patient was sufficiently stable to transition to the next lower level of care such as a partial hospitalization program (PHP) in order to facilitate her re-integration to a more normative setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation.  Findings:  Three physician reviewers found that the patients primary problem is recurrent bouts of sinus pressure/pain and drainage. Per the records, computed tomography (CT) of the sinuses was essentially normal, with no obstruction of the ostiomeatal complexes. Balloon ostial dilation has been used for many years for the treatment of specific sinus disease. In this case, the patients primary issues include poor sleep, fatigue and reduced productivity. The sinonasal symptoms are minimal, and there has been no medical therapy for treatment other than antibiotics. There is a lack of support for the requested services in this setting. Thus, balloon ostial dilation is not likely to be of greater benefit than other available treatment options. 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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

The parent of a female enrollee requested residential treatment services for medical treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the standard of care for adolescent depression, alcohol abuse, and eating disordered behaviors is psychotherapy and psychopharmacology. Residential treatment is not considered an appropriate treatment setting for patients with symptoms for less than 10 months, as in this patients case. Overall, the records demonstrate that the patient was a candidate for treatment in a less restrictive setting as she was medically stable. All told, residential treatment services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested for platelet-rich plasma injection for treatment of the enrollees chronic knee pain.  Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Middleton and colleagues concluded that despite its pervasive use, the clinical efficacy of platelet-rich plasma therapy in the healing of soft tissue injuries and varying mechanisms of action have yet to be established.  Moraes and colleagues concluded that overall, there is currently insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries.  There is a lack of long-term high-volume studies that establish the efficacy of leukocyte-poor, platelet-rich plasma therapy for intraoperative use to minimize postoperative inflammation or recurrent scar tissue formation in this clinical setting.  There is some evidence of benefit in the setting of cartilage or meniscal degeneration, which is not the case for this patient. Therefore, platelet-rich plasma injection was not likely to have been more effective than other treatment options.Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to recent suicidality and self-harm, significant recent aggression, property destruction, impulsivity, and substance use. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict. With regard to comorbidity, the records support a score of 3. The patient had significant co-morbidity, due to the presence of substance abuse and mental illness. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to struggles with performance expectations at home and at school. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents efforts to arrange treatment for patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment. With regard to treatment acceptance and engagement, the records support a score of 4. The patient demonstrated initial reluctance to engage in residential treatment and prior rejection of multiple outpatient providers. Thus, the patient has a total score of 24. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received at the residential treatment center. Therefore, the residential treatment center services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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: Overturned

A 56-year-old female enrollee has requested for a bariatric surgery consultation for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria set by the National Institutes of Health for weight loss surgery. The Swedish Obese Subjects (SOS) study has demonstrated that there is no long-term success to dietary plans. The efficacy of weight loss surgical procedures has been well established, and the requested consultation is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech-language disorder. Findings:  The physician reviewer found that Speech and language delay must be taken very seriously in young children as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The analysis provides, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. These reviewers conclude that this meta-analysis shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The patient in this case is a small child with severe speech and language delay that adversely impacts communication with those around him. These difficulties prevent him from acquiring the usual skills of childhood. In addition to expressive and receptive language delay, he exhibits feeding issues that affect his ability to obtain adequate nutrition. Successful feeding clinics incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. Speech therapy is imperative to this work. The current lack of underlying diagnosis does not negate the medical necessity of intervention for this child. This patient has significant delays in multiple areas and has not shown spontaneous improvement over time. He requires therapy to maximize his skills in communication and feeding. Speech therapy is therefore medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the requested medication in this patients case.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related conditions.  Harvoni has been approved by the U.S. Food and Drug Administration for all patients with chronic hepatitis C, genotype 1, regardless of fibrosis stage.  It is advantageous to treat patients before they progress to cirrhosis.  All told, the requested medication Harvoni is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has  requested Daklinza and Sovaldi for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to nonliver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi/Daklinza Sovaldi/PEG-interferon and ribavirin. This is based on the ALLY-3 study for Sovaldi/Daklinza and the Boson trial for Sovaldi/PEG-interferon with ribavirin (Nelson, et al; Foster, et al).  However, there is evidence that use of PEG-interferon self-injections can result in recidivism of intravenous drug use (Gigi, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel. Acthar Gel is U.S. Food and Drug Administration (FDA) approved therapy for the management of nephrotic syndrome (NS). Acthar Gel is not FDA approved or supported in the current medical literature for use as first-line therapy. Based on current data, Acthar Gel is reserved for patients with refractory NS. Madan and colleagues concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has NS that has not adequately responded to first-line therapy with corticosteroids. For these reasons, the requested Acthar Gel is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the breast. The Health Plan has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollees breast calcifications. At issue in this case is whether the magnetic resonance imaging (MRI) of the breast was medically necessary for treatment of the enrollees medical condition. Contrast enhanced breast MRI is a highly sensitive (greater than 90%) examination which has clear indications and can identify abnormalities that are occult on mammography and ultrasound. Indications for breast MRI include high risk screening; new diagnosis of breast cancer to evaluate for additional sites of disease; patients with positive margins after lumpectomy; evaluation of response to chemotherapy prior to surgery; evaluation for breast cancer recurrence; evaluation of metastatic cancer of an unknown primary source and lastly MRI may be used when mammographic/sonographic findings are inconclusive. The patient does not meet any of the above indications for breast MRI. She is not considered high risk and her mammogram and ultrasound were not inconclusive, as she underwent stereotactic biopsy to evaluate calcifications. The mammographic and sonographic findings should be fully evaluated and biopsy performed under mammographic or sonographic guidance as indicated. MRI is not appropriate to use as a problem solving tool in this setting. In this case, MRI was not medically necessary.Final Result: The reviewer determined that the service at issue was 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 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: Overturned

A 25-year-old female enrollee has requested coverage for excision of left axillary breast tissue.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  Breast reduction surgery is effective in relieving symptoms related to large breasts, such as back pain, neck pain, skin breakdown, and shoulder bra strap grooving.  Per the submitted documentation, the patient has shoulder bra strap grooving, neck pain, back pain, and rashes under her breasts.  The Health Plan has approved coverage for breast reduction surgery, but has denied coverage for left axillary breast tissue excision.  The axillary breast tissue is contiguous with the left breast tissue, and its removal is a medically necessary component of the bilateral reduction mammoplasty which has been approved by the Health Plan.  However, it is not a separately billable procedure.  All told, the requested excision of left axillary breast tissue is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Augmentative and Alternative Communication (ACC) device (Nova Chat 8) for treatment of the enrollees autism spectrum disorder and apraxia of speech. Findings:  The physician reviewer found that the requested device is medically necessary for treatment of the patients medical condition. AAC interventions are used for children with autism, often as stand-alone communication interventions for those who are minimally verbal. Colleagues suggest that AAC can be helpful for children with autism. In addition, the study by colleagues also found that there is growing evidence for the potential benefits of AAC for children with autism. Thus, the research shows that AAC is likely to benefit this patient with diagnoses of autism and apraxia of speech. Moreover, the documentation shows that the patient views iPad as a device to play and he has not shown the same level of skill development from the IPad. For the reasons provided, the requested device has been established as medically necessary for treatment of the patients autism and childhood apraxia of speech. Final Result: The reviewer determined that the requested device 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 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 parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees expressive language delay. Findings:  The physician reviewer found that the literature supports the use and medical necessity of intensive speech and language therapy for expressive language delay (Nelson, et al). This patient has expressive language delay with skills substantially below those of her peers. These deficits negatively impact her ability to communicate effectively with children her age and adults. Studies have shown that speech and language therapy can result in significant improvement in patients within this population. As such, it is medically necessary to provide speech and language therapy for this patient.