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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 15 hours of direct applied behavior analysis weekly. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees autism. The patient has been receiving applied behavior analysis (ABA) services from the provider and has made gains in many service areas. There was reports of challenging behaviors including aggression and lack of safety awareness. There were difficulties with communication. Current goals included safety, communication, tacting, and executive functioning skills. The medical records indicated slow progress with the current care plan; however, that may have been due to increasingly complex goals. A study found identifies applied behavior analysis (ABA) as the most effective form of treatment for children on the autism spectrum. Study results indicated that dose of treatment was positively associated with the number of mastered objectives, indicating that treatment that is more intensive leads to quicker and greater acquisition of skills. Thus, limiting access to treatment hours would have a negative impact, with fewer goals being mastered and duration of treatment lasting longer. The BACB guidelines specifies that supervision should occur for 20% of direct service time, or a minimum of 2 hours per week. As the provider is requesting 15 hours of direct treatment, the corresponding amount of supervision would be 3 hours per week.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 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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Mavyret . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus .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 should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C.  guidelines cite data showed reduced survival with delayed treatment. For these reasons, the request for Mavyret is supported as medically necessary for treatment of this patients chronic 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 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for magnetic resonance spectroscopy (MRS) of the brain (CPT 76390). In this case, MRS was performed as part of a diagnostic work-up in this patient with global developmental delays and microcephaly. Miscevic and colleagues noted that proton MRS, is one of the few techniques for in vivo assessment of neurometabolic profiles. The authors further describe the value of MRS in the discovery of neurochemical trends for clinical diagnosis and treatment monitoring in neurometabolic disorders in children. This patients global developmental delay, microcephaly, and hypotonia were highly suggestive of an underlying neurometabolic disorder and supported an indication for MRS. All told, the MRS of the brain (CPT 76390) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the MRS of the brain (CPT 76390) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 1 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in neurology with special qualification in child neurology and is 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 authorization and coverage for oral device E0486. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees sleep apnea.In this case, the patients clinical presentation indicates a diagnosis of OSA based on current diagnostic standards in the International Classification of Sleep Disorders. The enrollee is also noted to have clinically significant excessive daytime sleepiness on the basis of her Epworth sleepiness scale score. According to recently published joint practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine, the use of oral appliance therapy is generally accepted for patients who are intolerant of CPAP. In this patients case, it has been demonstrated that she meets the recommended criteria for oral appliance therapy. For these reasons, the oral device, E0486 is medically necessary.Final Result: The reviewer determined 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 neurology with sub-specialty certification in sleep medicine and 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the use of ENDURAgen (CPT 15275 51), provided to the left eye. In this clinical setting, based on the patients disease, the symptoms, and the results of published clinical trials, the use of ENDURAgen graft was superior to autografting with respect to indirectly lowering morbidity and risk by avoiding extended operating time and multiple operating sites for this patient. Enduragen is likely more beneficial than alternative methods for reconstruction involving autografting from other tissues, such as retro-auricular cartilage and hard palate. Other possible grafting materials include bovine extracellular matrix and human cadaveric material.  Cole and colleagues note the Enduragen material is either equivalent or superior to AlloDerm, DermaMatrix, and DuraMatrix with respect to direct surgical outcomes. Therefore, the use of ENDURAgen (CPT 15275 51), provided to the left eye, was likely to have been more beneficial for treatment of the pateint's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the ENDURAgen (CPT 15275 51), provided to the left eye, at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

In December 2003 this 38-year-old male patient underwent surgical reconstruction of his left anterior cruciate ligament (ACL). A standard hinged brace was used for approximately six weeks post-operatively. The patient then switched to a DonJoy brace.  The Health Plan indicates the patient could have been appropriately treated with a standard knee brace, and a specialized knee brace was not medically necessary.There is no class I data to suggest that the specialized knee brace at issue is more effective than a standard off the shelf type of hinged brace after an anterior cruciate ligament (ACL) reconstruction. There is no documentation of a limb deformity or any other compelling medical justification that would warrant the use of the DonJoy knee brace in this case. Therefore, I have determined that the specialized knee brace at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female has requested Synagis for treatment of the enrollee, who is status post bone marrow transplant.  Findings:  The physician reviewer found that in accordance with the American Academy of Pediatrics guidelines, California Childrens Services guidelines allow for palivizumab prophylaxis to immunocompromised children without age restriction. Children who have received bone marrow transplants have altered immunity long after their transplant has engrafted. In addition, those on immunosuppressant medications are also immunocompromised. Fighting RSV infection successfully requires all branches of the immune system to be intact. An absence or debility of any one branch may result in severe RSV infection, with resultant morbidity and even mortality. Although randomized controlled trials have yet to be performed (and may never be due to medicoethical reasons), one decision analysis model demonstrated a decrease in mortality in children after bone marrow transplant with the use palivizumab to protect against RSV-related lung disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture and an epidural for treatment of the enrollees pain.  Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the medical necessity of a portion of the requested services. Epidural steroid injections are indicated for acute radicular pain, spinal stenosis, neural foraminal stenosis, post laminectomy pain syndromes or acute herpes zoster.  This patient does not have any of these indications. Thus, an epidural steroid injection is not medically necessary for the treatment of this patient. Acupuncture may have efficacy in widespread pain syndromes, with only minimal side effects and complications. As acupuncture has provided some benefit in this patients case, it is medically appropriate. All told, the requested acupuncture is medically necessary for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of the requested epidural. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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 for a Fragile X test. Findings:  The physician reviewer found that the appropriateness of routine screening must be guided by current evidence-based scientific society guidelines. The ACMGs current prenatal screening recommendations for Fragile X syndrome are quite clear. This patient meets none of the family or personal history criteria for recommending Fragile X screening. Furthermore, an incomplete history on her fathers side does not constitute an increased risk above the general population risk.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for a continuous glucose meter. A continuous glucose monitoring system is one of several FDA-approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyper and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. A continuous glucose monitoring system can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. Continuous glucose monitoring systems have been shown to improve HbA1C levels of diabetic patients. They have been confirmed to be a very safe method, with high accuracy in glycemic values and a low complication rate. In this case, the patient has had erratic glycemic control and has been experiencing intermittent episodes of hypoglycemia. By using a continuous glucose monitoring system, she can mitigate this problem and improve her overall health. Therefore, a continuous glucose meter is medically necessary to treat the patients medical condition.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 internal medicine, with subspecialty certification in endocrinology, diabetes & metabolism, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings: Two reviewers found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result:  Two reviewers determined that the services at issue were 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: All three physician reviewers are 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for the enrollees routine breast cancer screening. Findings: Two physician reviewers found that the report revealed no evidence of cancer. The Health Plan has denied reimbursement for digital breast tomosynthesis as investigational for the evaluation of this patient. There is evidence-based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocols was likely to be more effective to the patient than had her examination been performed using two dimensional imaging alone.Final Result: Two reviewers have 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: All three physician 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks with RibaPak for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that 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. This applies regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed PEG-interferon and ribavirin with a protease inhibitor should be treated with regimens including Zepatier and ribavirin for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 93% cure rate. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier with RibaPak for 12 weeks 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: Upheld

Nature of Statutory Criteria/Case Summary: A review of the record indicates that the enrollee had a history previous spontaneous abortions and one live birth. The provider noted the enrollee was positive for the methylenetrahydrofolate reductase (MTHFR) mutation. The enrollees provider has recommended Nestabs 32mg for the enrollee.According to The American College of Obstetricians and Gynecologists (ACOG), `Homozygosity for the MTHFR gene mutation is the most common cause of hyperhomocysteinemia` which has been associated with a mild propensity to develop thromboses. Homozygosity for the MTHFR C677T polymorphism, as this patient has, is present in 1016% of all Europeans. However, MTHFR mutations by themselves do not appear to convey an increased risk of venous thromboembolism (VTE) in either non-pregnant or pregnant women and there are inconsistent associations between any inherited thrombophilias and recurrent pregnancy loss or stillbirth. Several studies have shown an association between MTHFR C677T homozygosity and recurrent pregnancy loss. The recommended treatment for MTHFR mutations in pregnancy is folate supplementation, usually at a dose of 0.8 to 1 mg per day though some studies have looked at doses up to 5 mg daily. Virtually all prescription prenatal vitamins contain 0.8-1.0 mg folate. The formulary options for this patient and Nestabs contain the same amount of folate equivalent even though Nestabs uses a methyltetrahydrofolate formulation. There is no data that this formulation improves outcomes in the setting of MTHFR mutations. Any prenatal vitamin would be adequate for decreasing the risk of miscarriage and deep vein thrombosis (DVT) in this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology, with subspecialty certification in maternal- fetal 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.