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

The parent of a 5-year-old male enrollee has requested applied behavior analysis (ABA) therapy for 25 hours per week for treatment of the enrollees autism. Findings:  Three physician reviewers found that in the peer reviewed medical literature, applied behavioral analysis (ABA) therapy has been shown to be effective in treating behaviors associated with ASD (Sallows and Graupner). In addition, the National Research Council recommends the use of ABA in young patients in this patient population and noted that treatments based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. In another study, a 5-year randomized-controlled study involving 48 children with autism and found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and ABA principles (Dawson and colleagues). This patient continues to have behavior issues including aggression, atypical sensory behaviors, and poor pragmatics, which are likely to respond to ABA intervention. The goals are to improve cognitive flexibility, pragmatic language and social functioning. ABA offers a program that is intensive, structured, individualized with explicit teaching of social skills, communication and learning to learn skills (Rogers and Vismara). This autistic patient has shown impressive gains in all domains since the start of therapies and will continue to benefit from intensive ABA therapy. As such, the requested 25 hours of ABA therapy per week are likely to improve this patients behavioral issues associated with ASD.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested proton beam therapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that proton beam therapy is not likely to be more effective for this patient than other available options. This is patient is young with early stage, low risk prostate cancer. The patient has several treatment options including surgery and radiation treatment for curative intent. The radiation treatment options that were presented include conventional intensity-modulated radiation therapy (IMRT), brachytherapy and proton beam therapy. Although there is medical literature that supports the safety and efficacy of proton beam therapy for prostate cancer, there is a lack of randomized trials suggesting superior clinical outcome of proton beam therapy for prostate cancer over the standard therapy of IMRT. Based on the documentation submitted for review, the requested services are not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for acupuncture services A 64-year-old male enrollee has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that The documentation provided do not support the medical necessity of the requested services in this clinical setting. For patients with low back pain, providers should consider the use of medications with proven benefits in conjunction with back care information and self-care. The medical literature in this clinical setting encourages assessment as to the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long term efficacy and safety data before initiating therapy. For most patients, first line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. For patients who do not improve with self-care options, providers should consider the addition of nonpharmacological therapies. For patients with acute low back pain, the literature recommends spinal manipulations. For chronic or subacute low back pain, the literature supports intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive behavioral therapy, or progressive relaxation. In patients with acute, subacute, mixed, or unknown duration of pain, other studies show that it is difficult to draw definitive conclusions regarding benefits and harms of complementary and alternative medicine (CAM) therapies in this patient population. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. With this patient, there is no sufficient demonstration of a patient workup or that he tried and failed treatments to justify the need for acupuncture. The provider has not documented any physical or orthopedic examinations of the low back, pain scales, functional deficits or failed conventional treatments. Therefore, with the lack of documentation of sufficient workup and prior treatments as well as the questionable long term effects of acupuncture, acupuncture services are not 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 oriental 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested tramadol and oxycodone for treatment of her medical condition.   Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for the requested medications has not been established. Per the documentation, not all non-opioid treatment options have been utilized nor is there no documentation of pain scores. There is no mention the patient has trialed behavior therapy given the support for its use. In addition, the Health Plans recommendation for physical therapy is medically reasonable and appropriate in this clinical setting.  All told, the requested medications are not medically necessary for treatment of the patients medical condition.  Final Result:  The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The physician 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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 1, due to a lack of recent clinical records.In terms of functional status, the records support a score of 1, minimal functional impairment, due to a lack of recent clinical records. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of autism spectrum disorder. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to struggles with academic performance and adjusting to online schooling. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents involvement and participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment as his symptoms worsened due to difficulty participating in virtual treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement, due to a reported lack of engagement with virtual treatment. Thus, the patient has a total score of 16. In this case, the recommended level of care is intensive outpatient services. Therefore, RTC services are not medically necessary for the treatment of 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 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: Urgent Care
Decision: Upheld

The parent of a 15-year-old female enrollee has requested psychiatric services for treatment of the enrollees psychiatric emergency. Findings:  The physician reviewer found the clinical documentation demonstrates the patient was not in a state of psychiatric emergency during the specified time. The patient was not immediately suicidal, nor did she exhibit overt impulsive behavior which was dangerous to others.  The patients symptomatology appeared to stem more from oppositional defiant disorder and perhaps part of a cluster B personality disorder than part of a true unipolar or bipolar depressive episode requiring immediate attention. Further, there was no indication from the records provided that the patient was unable to attend to her immediate self-care needs due to her psychiatric condition. As such, the patient was not experiencing a psychiatric emergency medical condition during the specified time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old female enrollee has requested proton beam radiation therapy for treatment of her lung cancer. Findings:  Three physician reviewers found that proton beam radiation therapy is not likely to be more effective for this patient than other available options. Proton beam radiation therapy has been used to treat several cancers including lung cancer in last several years. However, most of the published reports are retrospective studies with small number of patients or single institution phase II studies. There is a lack of published reports on the long term outcome of proton beam radiation therapy for the treatment of lung cancer from randomized controlled trials or cohort trials in peer reviewed literature. There are several ongoing phase II trials evaluating responses and toxicities of proton beam radiation therapy for lung cancer. In sum, there is a lack of long term clinical outcome data available demonstrating the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

 Nature of Statutory Criteria/Case Summary: An enrollee has requested a pelvic and abdominal ultrasound for evaluation of her medical condition.  Findings:  The physician reviewer found that the ultrasound examination was recommended for evaluation of severe pelvic pain. According to the American Institute of Ultrasound Medicine (AIUM), pelvic pain is an accepted indication for ultrasound evaluation. Bhavsar and colleagues noted that for non-pregnant women with pelvic pain, ultrasonography or computed tomography is indicated, depending on the possible diagnosis. The authors further noted that ultrasonography is preferred when ovarian pathology is suspected. Consistent with these findings, the requested pelvic and abdominal ultrasound is supported as medically necessary for evaluation of this patients pelvic pain.  Final Result: The reviewer determined that the requested diagnostic procedures are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for any or all residential treatment center (RTC) level of care.  Findings:  The physician reviewer found that he American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, this patient meets the criteria for RTC services from 8/15/22 and forward.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of suicidal ideation and multiple suicide attempts by overdosing on insulin. During the period under review, the patient denied suicidal ideation or urges to self-harm.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patient struggling with lack of motivation, lack of energy, and poor appetite prior to RTC admission. During the period under review, the patient appears to have improved and progressed, but these gains/stabilization have been achieved while participating in the highly structured and protected RTC program. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of a neurodevelopmental disorder, attention deficit hyperactivity disorder (ADHD), insulin dependent type 1 diabetes requiring intensive monitoring, and a history of dietary restriction. The patient has a history of taking excessive insulin. Dietary restriction and excessive insulin intake may be life threatening, and hypoglycemia may cause mood disturbance and increased anxiety.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for right coronary artery and left circumflex artery intracoronary stents with coronary angioplasty and a possible transcatheter MitraClip procedure. The patient has significant left ventricle dysfunction secondary to ischemic cardiomyopathy, but with viable myocardium noted on magnetic resonance imaging (MRI) study. He also has significant mitral insufficiency contributing to his severe dyspnea. Initially, he was considered for coronary artery bypass graft (CABG) and possible mitral valve repair, but a re-evaluation determined him to be at increased risk for open surgical procedure. He has two-vessel coronary disease without left anterior descending (LAD) coronary artery stenosis, making percutaneous coronary intervention of similar effectiveness to CABG and less invasive in this higher risk patient. Since he also has mitral insufficiency that may be contributing to his symptoms, combining this procedure with a percutaneous mitral clip placement may prevent the need for high-risk open surgery in this patient. Based on his higher surgical risk, non-LAD CAD, and mitral valve disease, these percutaneous procedures provide the lowest risk and least invasive ways of treating his cardiac conditions. Given this support, the requested right coronary artery and left circumflex artery intracoronary stents with coronary angioplasty and a possible transcatheter MitraClip procedure is 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 board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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:  The enrollee requested coverage for Autonomic Nervous Function Test. The enrollee underwent autonomic nervous function testing after experiencing ongoing symptoms of dizziness, chest pain, dyspnea, tachycardia, near syncope and burning/tingling sensations.  The documentation indicated she initially underwent a cardiac consultation complaining of three episodes of pre-syncope.  The documentation detailed the enrollee has seen a pulmonologist and pulmonary function testing did not identify a reason for this.  She has also seen gastroenterology and endocrinology.  The physical examination did not reveal any significant abnormalities.  The patient's laboratory studies were normal.  An ECG showed normal sinus rhythm.  The recommendation was made for the patient to undergo additional testing to include an echocardiogram, as well as a Holter monitor and autonomic reflex screening to rule out dysautonomia.  Testing revealed an ejection fraction of 55 to 60%.  She had a good exercise tolerance and the tilt table testing revealed mild generalized autonomic impairment within the adrenal genic system.  The tachycardia response was in excess of the blood pressure drop, which was consistent with postural orthostatic tachycardia syndrome.According to the medical literature, postural tachycardia syndrome (POTS) is defined by a heart rate increment of 30 beats/min or more within 10 minutes of standing or head-up tilt in the absence of orthostatic hypotension. The standing heart rate is often 120 beats/min or higher. The documentation detailed the enrollee was being evaluated for autonomic nervous dysfunction for which autonomic nervous function testing was performed.  The requested testing is considered appropriate in combination with tilt table testing given the need to monitor the bodys different responses to be able to diagnose the patient with conditions such as postural orthostatic tachycardia syndrome.  This enrollee has had a history of dizziness and presyncope for more than ten years.  When she has these episodes, she sometimes experiences shortness of breath, palpitations and gastrointestinal symptoms. Some orthostatic changes have been noted.  The enrollee underwent autonomic nervous function test, which allowed physicians to have quantitative data to follow her progress with different treatments.  The fact that this testing allows guidance of therapy, which in this case did lead to improvement of her symptoms, proves its value.  Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Cardiology. All are 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3.  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 non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% (Foster, et al). The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Epclusa 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 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.