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

A 59-year-old male enrollee has requested LifeVest wearable cardioverter with external defibrillator for treatment of his medical condition status post myocardial infarction.  Findings:  Two physician reviewers found that based on the records provided, this patient suffered an acute cardiac arrest in the setting of ischemia and non-ST segment elevation myocardial infarction after an exercise stress test. He was subsequently stabilized and underwent urgent coronary revascularization.  At the time of cardiac catheterization, his ejection fraction was reported to be 50-55%. In this circumstance of ventricular fibrillation during a myocardial infarction, relatively preserved ejection fraction (greater than or equal to 50%), and subsequent coronary revascularization, further risk of sudden cardiac arrest is not elevated to a degree where an implantable cardiac defibrillator (ICD) is medically indicated. Moreover, the documentation does not indicate that the patient had reduced ejection fraction of less than or equal to 35% and did not suffer recurrent ventricular tachycardia or ventricular fibrillation after coronary revascularization on the said date. A wearable external defibrillator would be indicated only if the criteria for an ICD were met and an ICD could not be placed, needed to be delayed, or required explantation. The criteria for ICD placement appropriately requires a period of time, generally 40 days post myocardial infarction or 3 months after newly recognized cardiomyopathy, prior to ICD placement. As noted by Gronefeld and colleagues, the efficacy of prophylactic defibrillators used earlier than 40 days after myocardial infarction, or at the time of coronary bypass has not been proven in the medical literature. In summary, a prophylactic wearable defibrillator has not been shown in the medical community to have clinical value in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most 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 or viral load. Per the AASLD/IDSA guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni 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 gastroneterology 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 58-year-old female enrollee has requested prescription medication Lyrica for treatment of left arm pain.  Findings:  The physician reviewer found that there are many standard therapies available for the treatment of cervical radiculopathy including physical therapy, narcotic pain medications, oral steroids, epidural steroids, and a variety of medications for neuropathic pain. Lyrica is not generally a first or second-line agent for radicular pain,  and there are no studies supporting its use in this instance.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested radiofrequency ablation/neurolysis of the sacroiliac joint and lumbar spine (including CPT codes 64622 and 64640) for treatment of her degenerative disc disease and sacroiliac joint dysfunction.  Findings:  Three physician reviewers found that this patient reported significant pain relief from the right sacroiliac (SI) joint injection, which is a clinical indication that she will benefit from the requested procedures. The available peer reviewed medical literature suggests that radiofrequency (RF) ablation of the SI joint is no longer investigational. Further, Ferrante and colleagues concluded that RF denervation has been shown to be efficacious for about six months of pain relief when used in patients with a successful SI joint injection. As this patient reported 100% pain relief with the SI joint injection and 50% or more relief at 6-week follow-up, she is an appropriate candidate for the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for proton beam radiation therapy. Compared to standard radiotherapy with photon intensity modulated radiation therapy (IMRT), proton therapy features a Bragg Peak, which translates into decreased exposure of normal tissue in the low- to intermediate-dose range. For this patient, the clinical benefit of proton therapy is of critical importance. The patient received craniospinal irradiation, which involves radiotherapy to the entire brain and spine. Using a photon technique, there is significant exit dose going through all of the organs in front of the spine. Conversely, utilizing a proton approach, the Bragg Peak avoids almost most of the exit dose. Researchers compared acute toxicities between photon-based craniospinal irradiation and proton-based craniospinal irradiation. The authors found less weight loss, grade 2 nausea and vomiting, and less grade 3+ esophagitis in patients treated with photon therapy. Given its advantages over photon therapy, proton therapy was expected to substantially decrease the risk of radiation-induced secondary malignancies. All told, the proton beam radiation therapy was likely to be more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation 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: Experimental/Investigational
Decision: Upheld

A 33-year-old male enrollee has requested intravenous immune globulin infusions for the treatment of his multiple sclerosis. Findings:  Two physician reviewers found that there is a lack of support demonstrating the efficacy of intravenous immune globulin for treatment of relapsing and remitting multiple sclerosis. As indicated in the meta-analysis cited above, additional studies are needed to establish the role of IVIG in the management of multiple sclerosis. It appears Cytoxan has been proposed in this case. The efficacy of intravenous immune globulin in this clinical situation has not yet been established and there is no evidence to indicate that it is superior to other standard therapies in this setting such as Cytoxan.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female has requested ventral hernia repair, reconstructive abdominoplasty, and abdominal panniculectomy for treatment of her pannus and intertrigo dermatitis.  Findings:  The physician reviewer found that the reviewed records do not justify the medical necessity of the requested ventral hernia repair as it is unclear that she actually has such a hernia. The ultrasound did not view the area where the ventral hernia is reported to be.  Although the patients surgeon has reported a hernia, the documentation does not report the size of the fascial defect or exactly where it was located along the vertical scar. Abdominoplasty is a procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward.  It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons.  Thus, the medical necessity of the requested abdominoplasty has not been demonstrated in this patients case.  Panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions.  The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary. Given the absence of documentation of a skin condition related to the pannus that is refractory to medical treatment, the submitted records do not support the medical necessity of the requested abdominal panniculectomy.In the absence of an infraumbilical hernia, the records do not document any condition which constitutes an abnormal structure of the body or a functional impairment. Thus, the requested reconstructive abdominoplasty and abdominal panniculectomy are not reconstructive in nature.  All told, the requested ventral hernia repair is not medically necessary for the treatment of this patient.  The requested reconstructive abdominoplasty and abdominal panniculectomy are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Anser IFX measurement of serum infliximab and antibodies to infliximab (ATI) for treatment of his medical condition. Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. The loss of response to infliximab can be due to sub-therapeutic infliximab levels or the presence of antibodies to infliximab. While more research is needed to fully explore this area, the available data suggest that measuring drug and/or antibody levels could help clinicians to optimize anti-TNF therapy by adjusting drug doses or switching to alternative therapies in patients who are unlikely to respond to continued treatment with a particular agent. The concept of dose adjustment based on drug levels has several potential benefits, one of which is that providers could not only increase drug doses in patients with sub-therapeutic drug levels but could also reduce drug doses in patients with super-therapeutic levels, thereby making the treatment safe for the patients. Therefore, measuring both IFX and ATI concentrations may help guide patient management, optimize care, and prevent complications and reduce long-term morbidity and mortality from complications. In this patients case, Prometheus Anser IFX testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the testing 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and 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

A 26-year-old female enrollee has requested modafinil (Provigil) for treatment of her shift work sleep disorder (SWSD).   Findings:  The physician reviewer found the submitted clinical documentation demonstrates the patient has a confirmed diagnosis of shift work sleep disorder. Shift work sleep disorder is a recurrent pattern of sleep disruption which results in functional impairment in the form of insomnia or extreme sleepiness. The patient has been symptomatic with persistent insomnia. Provigil is indicated for the treatment of shift work sleep disorder and has established efficacy in this setting. The submitted records indicate the patient has taken Provigil in the past with good response. All told, the requested modafinil (Provigil) is medically reasonable and necessary to treat the patients shift work sleep disorder, as it results in functional impairment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old male who may have a history of fungus infection of his toenail and fingernails. A fungus culture reported in December 2004 grew out penicillium species. Coverage for a prescription for Lamisil tablets has been denied by the Health Plan. At issue is whether Lamisil is medically necessary for treatment of the patients condition.The records provided do not include a detailed history of a dermatology physical exam. As such, it is not known if the patient is experiencing a functional impairment. Furthermore, the presence of penicillium in a fungus culture may indicate either pathogen or non-pathogen containment. It appears further workup is needed in this case and the patient should be evaluated by a dermatologist. The submitted documentation does not demonstrate the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male with coronary artery disease. He has requested reimbursement for EECP therapy. Information provided indicates the patient had a myocardial infarction in 2001. In 2002, a thallium stress test revealed inferior basal wall ischemia, apical defect and hyperkinesis. The patients provider diagnosed the patient with asymptomatic angina and recommended treatment with EECP. The Health Plan has denied reimbursement for the EECP.The Health Plans denial should be upheld. The patient does not have documented angina or congestive heart failure. In 2002, the American College of Cardiology and American Medical Association issued a joint statement indicating EECP is considered experimental. In 1999, Medicare approved EECP as a reasonable and necessary treatment for certain patients suffering from stable angina pectoris refractory to medical and/or surgical therapy. Further, under Medicare guidelines, coverage for EECP is provided for patients who have been diagnosed with disabling angina who in the opinion of a cardiologist or cardiothoracic surgeon are not readily amenable to surgical intervention.Although EECP has a place in the management of angina pectoris and congestive heart failure refractory to conventional therapy, the information presented does not demonstrate this patient has either condition or that he failed first-line therapy prior to EECP. Therefore, I have determined the therapy 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for irreversible electroporation (IRE). Epithelioid hemangioendothelioma is a soft-tissue sarcoma with histologic markers that suggest an endothelial origin. There is no well-defined treatment strategy for hepatic epithelioid hemangioendotheliom. Epithelioid hemangioendothelioma is poorly responsive to chemotherapy, immunotherapy, and radiotherapy, as well as several other treatment modalities. In addition, surgical resection and transplantation are highly invasive and complicated by rejection issues. IRE is a non-thermal focal ablation method which kills cells non-thermally but spares structures such as extracellular matrix, blood vessels, and bile ducts; it has shown safety and efficacy even in tumors which were ineligible for or refractory to conventional therapies. IRE has been demonstrated to be safe and effective for the treatment of epithelioid hemangioendothelioma and is less invasive than surgery or transplant. In this case, the patient has epithelioid hemangioendothelioma with no well-defined treatment strategy. IRE is a viable treatment option with demonstrated safety and efficacy, compared with alternatives, which are associated with significant adverse effects or invasiveness. For these reasons, the requested IRE 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 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

The mother of a 17-year-old female enrollee has requested continued care at a residential treatment center for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that on admission to the RTC, the patient was almost 100% of ideal body weight.  There were no medical issues, no suicidal ideation, no homicidal ideation, or psychosis.  She was cooperative and progressed well in treatment. There is no clinical evidence that the patient continued to require the intensity of RTC services. At that time the medical records demonstrate the patient was appropriate for a less intense level of care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-six-month-old male enrollee has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that there is a robust medical literature advocating speech therapy for autistic children. The scientific literature strongly supports speech therapy for autistic children. Myers, et al. state, People with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services.  Turner, et al. reported the results of a controlled study comparing autistic children, who did and did not receive speech therapy.  Those that did receive therapy had far greater communication skills than those that did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.All told, based on the patients diagnosis of autism and documented deficits, he is an appropriate candidate for speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested coverage for speech and language therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the scientific data suggests that the plasticity of the developing brain enables the retraining of neural circuitry not compromised by the underlying pathogenetic processes that give rise to ASD including speech and language delay. As noted by Paul, young patients with ASD, benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Thus specific treatment, including speech and language therapy, can be used to help induce brain plasticity with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and the associated developmental delays. In conclusion, there is adequate evidence demonstrating that speech and language therapy in an individualized setting can have a positive outcome on development of useful speech. Accordingly, I have concluded that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested eating disorder residential treatment center services for treatment of the enrollees anorexia.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience.  In this patients case, the documentation provided does not support placement at the residential level of care.  This patient was having difficulty with eating disordered behavior in the home environment despite intensive outpatient programming.  She had done well at the partial hospital level of care from during the time frame specified before being stepped down to intensive outpatient program services.  At the time of admission, the patient was 52 tall and weighed 122 pounds.  Her body mass index was within normal limits.  Per the medical records, she required comprehensive treatment, with an emphasis on family therapy, to address her drive for thinness, anxiety, depression, identity formation struggles and family dynamics.  However, based on the peer-reviewed medical literature, treatment in a 24-hour supervised setting was not indicated.  Since the patient had just recently done well with partial hospitalization, it would have been medically appropriate to resume partial hospitalization level of care during the dates of service at issue.  All told, eating disorder residential treatment center services provided from the time frame specified were not medically necessary for the treatment of this patient.