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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) (20 grams every two weeks).Findings:  The physician reviewer found that dysautonomia as an umbrella term referring to any disorder associated with dysfunction of the autonomic nervous system. The authors further note, There are many different mechanisms by which dysautonomia may arise, but there has been increasing evidence and awareness that it may be immune-mediated in some patients. Autoimmune autonomic dysfunction may be peripheral due to an immune-mediated small fiber polyneuropathy (SFPN). SFPN may manifest clinically as postural tachycardia syndrome, orthostatic intolerance, orthostatic hypotension, inappropriate sinus tachycardia, gastrointestinal dysmotility, complex regional pain syndrome, and/or neurogenic bladder. The authors recommend IVIG as a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Based on a retrospective analysis of 38 patients with refractory autoimmune dysautonomias, the authors concluded, There is increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. A 4-month IVIG trial should be considered in severely affected patients who are refractory to lifestyle and pharmacological therapies. In this case, the patient has an underlying autonomic nervous system dysfunction that has been refractory to multiple treatments. Given that current medical literature demonstrates clinical improvement in patients with dysautonomia with IVIG treatment, the requested services are medically indicated. Therefore, IVIG (20 grams every two weeks) is medically necessary for the 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 neurology 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 authorization and coverage for intensity modulated radiation therapy for treatment of his high-grade malignant peripheral nerve sheath tumor with heterologous rhabdomyoblastic differentiation.Findings: Three physician reviewers found the provider has recommended intensity modulated technique to deliver adjuvant radiation therapy to the surgical bed. There is clinical data to support the use of IMRT in the treatment of sarcoma. The medical literature has demonstrated decreased bone damage and improved local control when using IMRT compared to standard three-dimensional conformal planning.  A standard three-dimensional conformal plan would be unable to spare the femur and inguinal skin region in this case. Consensus group guidelines support the use of IMRT for this cancer. Based on these reasons, IMRT is likely to be more beneficial for treatment of the patients medical condition than standard therapy.Final Result: Three physician reviewers determined that the requested services are 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: All three reviewers 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: Overturned

The parent of a four-year-old male enrollee has requested for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  Three physician reviewers found that according to a well-respected general pediatrics textbook, there is compelling evidence that intensive behavioral therapy, beginning before three years of age and targeted toward speech and language development, is successful in improving both language capacity and later social functioning. The authors also note that controlled studies of early intensive 1:1 behavioral training (ABA) have resulted in significant cognitive and behavioral gains. Multiple studies comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality have shown that the behavioral treatment groups exhibited greater increases in IQ and adaptive functioning, and fewer aberrant behaviors and social problems, than did the eclectic groups. Behavioral therapy is considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy. Many consider the advances made in the treatment of children with autism spectrum disorders to be attributable to early intervention with ABA techniques. ABA therapies have been utilized and studied for decades, and the data indicates positive results with consistent implementation of this method. ABA is considered standard of care, particularly in early intervention programs, by many experts in the field.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested Xolair for the treatment of her condition. Findings:  The physician reviewer found that systemic steroids over a long period of time reduce serum immunoglobulin levels. This is one reason why the total IgG is not elevated to a significant degree. Xolair is medically appropriate considering both the documented atopy and the severity of her disease. The Health Plans denial is not appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested individual therapy with a licensed clinical social worker once a week for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the request for individual therapy with a licensed clinical social worker once a week is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient is documented to be cooperative and pleasant with no psychomotor agitation. Her thought process is linear and her cognition is normal. Her insight and judgment are also noted to be good. The records revealed that this patient is more relaxed and not showing dysphoria. In addition, a therapy note reported that her compliance with treatment has been excellent. In sum, her mental status shows no distress or abnormality that requires weekly individual therapy. Based on the medical records provided for review, individual therapy with a licensed clinical social worker once a week has not been established as medically necessary. 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 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

A female enrollee requested digital breast tomosynthesis (77063) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the medical literature indicates that the use of this additional technique may result in earlier detection of small breast cancers as well as a decrease in call back rates for diagnostic work-up.  Thus, the addition of digital breast tomosynthesis to screening digital mammography was likely to be of greater benefit for this patient than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old male with brain cancer and partial left side paralysis. He has undergone a biopsy and received chemotherapy and radiation therapy. He has also received rehabilitation. His other medical history is unremarkable. He is seeking authorization for acupuncture and claims it has aided in improved motor function. The information submitted does not document acupuncture is indicated for this patient. No records have been submitted demonstrating a documented objective response to acupuncture. Furthermore, no evidence has been submitted supporting the use of acupuncture for this patients condition. With such evidence lacking, there is no documentation indicating the medical necessity of acupuncture. Therefore, I have determined the requested therapy is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 13-year-old male diagnosed with pervasive developmental disorder, depressive disorder and intermittent explosive disorder.  He was treated emergently in October 2005 and held for acute psychiatric hospitalization due to gross violence against his mother.  While at home, he became angry about what she was preparing for dinner and grabbed her by the throat and shoved her head against the kitchen cabinets. He had a prior history of violence inclusive of punching and biting his mother two weeks prior and an episode of choking her one-year prior when he was again upset about what she was preparing for dinner. The patient had also been admitted for inpatient psychiatric treatment four years prior due to behaviors that included charging at family members with a knife. His mother reported that although he had a long history of depression and low self-esteem, the severity of his behavioral disruptions had grown significantly in the past four years. He frequently refused to attend school and had explosive outbursts on the subject of food. The family also noted him to be preoccupied with fast food, wanting to be taken there each night. If his parents did not comply with his demands, he became angry, threatening, and/or violent. At that time of admission, the patient was attending a modified public school program and beginning in June 2005, his depression was successfully treated with Cymbalta 60 mg.With regard to his hospitalization, he was described as concrete in his reasoning with difficulty in his expression of feelings, having difficulty with change, having only a few close friends, and being hypersensitive to smells and tactile sensations. He was begun on Depakote and his dosage was gradually titrated upwards. Though he was initially a bit placid, by October 2005 he was noted to have grown increasingly rude and very resistant to any interaction when a change in his diet was related to him. At issue is whether the acute inpatient psychiatric care the patient received from October 2005 through November 2005 was medically necessary.As noted in the aforementioned notes, the patient did not appear appreciably improved by October 2005.  There is ample documentation pointing to his irritability, intolerance, and provocation.  These behaviors were of great concern and particularly problematic in light of his pattern of violence at home. Safe and appropriate discharge required that the treating clinician be as sure as possible that the patient had improved before sending him home.  He was assessed as sufficiently stable for discharge as of November 2005.  All told, I have determined that the acute inpatient care at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested low back fusion surgery for treatment of his low back pain. Findings:  The physician reviewer found that fusion may be indicated for instability of the spine from trauma, tumor, infection, or iatrogenic instability, but rarely for abnormal radiographic results without appropriate clinical findings. There is no strong correlation between MRI changes and low back pain. Improvement can be expected in patients treated with fusion, regardless of technique, when an established indication exists. In most patients with low back pain, symptoms resolve without surgery. For back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, and diffuse low back pain without an explainable functional deficit is not an indication for fusion.  Arthrodesis has a poor success rate when used to treat back pain associated with multiple level disc degeneration seen on MRI images, and multilevel fusions are associated with an increased rate of complications and revisions.  In this case, there is no documentation of conservative care, other than the report of a failure of physical therapy and one epidural steroid injection. There is no documentation of instability of the spine, nor is there any evidence of the presence of a condition, such as trauma, which would elevate the risk of instability. All told, the requested low back fusion surgery is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested IVIG infusion for treatment of her Raynauds phenomenon.  Findings:  The physician reviewer found the patient has been diagnosed with a presumed undifferentiated connective tissue disease based largely on her symptoms. The patients serologic profile has been largely unremarkable including an ANA titer of 1:40, which is clinically insignificant. As part of the serologic workup, a persistently low level of IgG subclass 2 has been noted in the absence of generalized hypogammaglobulinemia. She has a history of recurrent sinopulmonary and urinary tract infections, but no evidence of inadequate humoral response to immunization to support humoral immune dysfunction. These criteria are needed to support the use of IVIG replacement therapy, as levels of IgG subclasses outside of the reference range can commonly occur in the absence of any actual immune dysfunction (Bonilla, et al; Gelfand et al). As the literature does not support IVIG as the standard therapy for undifferentiated connective tissue disease, scleroderma, or lupus, the only justification for its use in this case would be for documented humoral immunodeficiency. However, there is a lack of documentation of an inadequate antibody response to immunization to support the use of IVIG for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart, without contrast, with quantitative evaluation of coronary calcium. In this case, the patient has increased coronary risk. The ACC and American Heart Association (AHA) clinical practice guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary calcium quantification, coronary CT scanning, advanced lipoprotein analysis, genetic testing, and homocysteine. While the results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of data from controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes over those achievable with treatment based on standard risk factor profiling and basic lipid analysis. Therefore, CT scan of the heart, without contrast, with quantitative evaluation of coronary calcium is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested CT scan of the heart, without contrast, with quantitative evaluation of coronary calcium is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease 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: Upheld

A forty-nine year-old male with chemotherapy induced peripheral neuropathy is requesting authorization for Anodyne treatment.  Reviewers Findings:  The reviewing physician found that Anodyne is not currently among the accepted standard of medical care for treatment of chemotherapy induced peripheral neuropathy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary.  An enrollee has requested Novacure-Optune tumor treating fields (TTF) for treatment of the enrollees glioblastoma.   Findings: Three physician reviewers found that the patient is diagnosed with glioblastoma multiforme (GBM). The patient was diagnosed in and treated with surgical resection followed by radiation in combination with temozolomide. A follow-up magnetic resonance imaging showed possible progression versus radiation necrosis. The patients provider recommended treatment with Novacure-Optune tumor treating fields (TTF) as maintenance therapy in combination with temozolomide. The Health Plan has denied this requested device as investigational for treatment of this patient. There is sufficient medical evidence supporting Novacure-Optune TTF therapy, also known as alternating electric field therapy, for treatment of patients diagnosed with GBM.  The National Comprehensive Cancer Network has endorsed TTF therapy as maintenance therapy along with temozolomide in patients with supratentorial lesions, as in this patients case.  Moreover, the device is approved by the U.S. Food and Drug Administration for use in maintenance therapy after primary treatment is completed. The patient was treated with surgical resection followed by radiation therapy. Therefore, Novacure-Optune TTF therapy is likely to be more beneficial than existing therapies for treatment of this patient. Final Result: Three physician reviewers have determined that the requested device is 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: All three physician reviewers are board certified in internal medicine 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 lumbar spinal fusion surgery. The submitted documentation supports the medical necessity of the requested services. He has failed nonoperative measures. The provider has deemed him to be a good candidate for spinal fusion. Spinal decompression for spinal stenosis is associated with a good outcome.  Translumbar interbody fusion is associated with a high fusion rate, and when combined with decompression, it increases the probability of a good outcome, particularly if iatrogenic instability is created. There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone lumbar interbody fusion has good clinical outcomes. There is sufficient support for the requested services in this clinical setting. Therefore, the requested lumbar spinal fusion surgery is medically necessary for the 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 orthopedic surgery 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: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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.