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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Optune System (HCPCS Code E0766). Optune System tumor treating fields (TTF) therapy is delivered locally through a physical, nonchemical pathway, which allows TTF therapy to treat brain tumors. The available data on the Optune System demonstrates that the device is safe and does not cause cumulative damage to healthy cells in the body. Lu and colleagues noted that the Optune System is focused to affect only one cell type at a time. Since the fields alternate rapidly, there is little effect on normal cells. This patient has been treated with resection, chemotherapy, and radiation with progressive disease. Consistent with the support in the current peer-reviewed medical literature, the patients provider recommended treatment with the Optune System. All told, the Optune System (HCPCS Code E0766) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Optune System (HCPCS Code E0766) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the equipment at issue was and 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: Physician reviewers 1, 2, and 3 are board certified in neurological surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism spectrum disorder.  The physician reviewer found that in this case, the patient is appropriately receiving ABA services for his diagnosis of ASD.  The review by Reichow and colleagues indicated that early intensive behavioral intervention for children with ASD was extremely effective. The requested speech therapy and occupational therapy are not clinically indicated at this time. In this case, ABA is the most effective intervention for a non-verbal child with ASD. Traditional speech therapy requires sitting in a room repeating sounds and naming pictures and at this time, the patient is not yet ready for this type of therapy. However, after a period of of intensive ABA therapy he may be ready. In this setting, play-based interactions with ABA are clinically indicated to work on his speech. In addition, early intensive behavioral intervention can provide some play based interactions to promote the understanding of communication. As such, the request for speech therapy is not medically necessary. In addition, occupational therapy is also not medically necessary at this time. Occupational therapy focuses on teaching the child to learn fine motor and adaptive skills, however this is not appropriate therapy for this patient at this time. In this clinical setting, ABA services are clinically indicated and should be his focus, however speech and occupational therapies are not 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of promethazine with codeine syrup for treatment of the enrollee who has a history of chronic asthma.Findings:  The physician reviewer found that there is a lack of support in the documentation provider for the medical necessity of the requested medication. The medical literature recommends caution when prescribing opioids at any dosage. In this patients case, the record indicates that this patient is already taking daily opiates for chronic pain syndrome. The U.S. Food and Drug Administration (FDA) approved promethazine codeine syrup for temporary relief of cough due to the common cold or allergy. The intent for its approval was to provide short-term treatment for a cough. Additionally, the FDA did not approve promethazine with codeine syrup for daily use of a year or more as requested in this patients case. Accordingly, additional opiates may place this patient for a high potential of abuse. As such, the use of promethazine with codeine syrup is not medically necessary for treatment of this patients medical condition.] Final Result: The reviewer determined that the requested medication is 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 internal medicine with sub-specialty certification in pulmonary disease 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 patient has requested authorization and coverage for Home infusions of Octagam 50 grams daily for three days, then 75 grams every four weeks thereafter. In the peer-reviewed medical literature, there is increasing evidence that immunomodulation with intravenous immunoglobulin (IVIG) is helpful in treating patients with autonomic dysfunction and Sjogrens disease. However, these studies are small and there is a lack of national guidelines to recommend this therapy. Scientists conducted a study evaluating IVIG in patients with autoimmune dysautonomias. The authors found increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. Moreover, the authors noted that, Antiphospholipid antibodies and novel Sjogren antibodies are often present in these patients and correlate with a high response rate to IVIG. In this case, the patient has been treated with prednisone, Pamelor, Lyrica and Cosentyx for chronic inflammatory sensory polyneuropathy. The medical records provided do not demonstrate a diagnosis of Sjogrens or adequate documentation to support the diagnosis of peripheral neuropathy to support an indication for IVIG. For these reasons, the requested home infusions of Octagam 50 grams daily for three days, then 75 grams every four weeks thereafter are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 internal medicine with subspecialty certifications in allergy and immunology and rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested for gastric bypass surgery for treatment her morbid obesity.   Findings:  The physician reviewer found that a review of the record indicates the enrollee is 67 inches tall, weighs 235 pounds, and has a body mass index of 36.8. She reports a history of methamphetamine dependence and weight gain when she stopped using the drug. The enrollee has significant gastro-esophageal reflux disease (GERD) and recent endoscopy showed linear erosions at the esophageal-duodenal junction for which she takes Omeprazole. She has tried supervised and unsupervised weight loss programs, exercise and medications without successful long-term weight reduction. The enrollee completed nutritional and psychological evaluations and was found to be a viable candidate for bariatric surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient presented with a history of nasal trauma and difficulty breathing for several months. On physical examination, there was no sinus tenderness and no boggy mucosa. She was referred to an otorhinolaryngologist (ENT). Nasal trauma is a common etiology for nasal obstruction, and functional rhinoplasty has been shown to be an effective method for treating nasal obstruction. Specific maneuvers can address deformities like septal deviation, nasal and septal fractures, valve collapse, and inferior turbinate hypertrophy. Each of these may contribute to nasal obstruction and require thorough evaluation for consideration by a specialist. This patient had nasal obstruction after nasal trauma. Thus, evaluation and treatment by an In-Network ENT is medically necessary.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 otolaryngology with subspecialty certification in plastic and reconstructive 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

A 61-year-old male enrollee has requested the medication Xolair for the treatment of his allergic rhinitis. Findings:  The physician reviewer found that in this particular patient, Xolair was clinically effective when standard therapies failed. The patient has experienced marked chronic discomfort and insomnia despite standard therapy.  Xolair has been demonstrated to help patients with allergic rhinitis, and in particular this patient.  It appears this patients illness has evolved from standard allergic rhinitis to combined rhino-sinusitis with associated nasal polyposis.  This patient represents a small percentage of rhinitis patients, and Xolair is medically necessary due to a lack of other options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: There is support in the medical literature for the requested medication in this clinical setting. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B, In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy is medically necessary for the treatment of this patients hepatitis B. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male has requested approval for Euflexxa shots, four times per year for treatment of his shoulder pain.   Findings:  Two physician reviewers found that the patient has a history of shoulder pain, low back pain, and leg pain.  The medical records noted a diagnosis of shoulder osteoarthritis.  In an undated letter, the patient reported prior surgery to the left shoulder, with no benefit.  He noted that physical therapy has been ineffective.  The requested services are not likely to be of greater benefit than other treatment modalities in this clinical setting.  Hsieh and colleagues compared a cohort of 70 patients with adhesive capsulitis of the shoulder randomly placed into one group receiving hyaluronic acid injections with physical therapy and a second group receiving physical therapy alone.  Both groups experienced improvements in pain, disability, and quality of life after treatments.  However, no significant group effect was found for any outcome measurements.  The authors concluded that intra-articular hyaluronate injections did not produce added benefits for adhesive capsulitis of the shoulder.  There is a risk of either infection or sensitivity reaction to the injected material, especially with repeated injections.  All told, the requested Euflexxa shots, four times per year, are not likely to be more efficacious than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer found that 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 except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  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 infection regardless of fibrosis stage.  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 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: The spouse of an enrollee has requested reimbursement for acute psychiatric inpatient treatment services that were provided to the enrollee. Per colleagues, patients with major depressive disorder may be treated outside of a hospital setting with the lack of dangerous behaviors. Per colleagues, ECT is routinely administered on an outpatient basis for patients that are not exhibiting dangerous behaviors and are free from suicidal and homicidal ideation. In this case, the patient was not exhibiting dangerous behaviors towards herself or others and was fully cooperative in treatment. The patient could receive her mental health treatment in a setting that is less restrictive than an inpatient psychiatric setting, due to her overall stable symptoms. She was not noted to have any severe mood swings or other symptoms associated with her mood disorder. Therefore, the acute inpatient psychiatric services that were provided to the patient were not medically necessary.Final Result: The reviewer determined that the services at issue were 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 subspecialty in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 60-year-old male diagnosed with osteoarthritis (OA) of the left knee. The patient endorsed left knee pain for over six months. He has tried and failed physical therapy, analgesics, non-steroidal anti-inflammatory drugs, bracing, and corticosteroid injections. The patient reported difficulty sleeping due to pain. The patients provider reported that total knee arthroplasty would be an option if all conservative options have failed. At issue in this case is whether Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition. Intra-articular hyaluronic acid (IAHA) provides a moderate symptomatic benefit to knee OA patients and without major safety concerns. IAHA offers one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, gain in quality-adjusted life years and substantial delays in time to total knee replacement. Viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and for patients where conservative treatment has failed and the options are limited. In this case, standard treatments have been tried and failed with the alternative treatment being a total knee arthroplasty. Therefore, Euflexxa injections for the left knee are 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: The patient was diagnosed with autism spectrum disorder who has been treated with applied behavior analysis (ABA). The patient's Vineland Adaptive Behavior Scale 3 (Vin-3) scores were noted to be low for his age group. The patients parent has requested reimbursement and coverage for 36 hours per week of direct 1-on-1 ABA services. The Health Plan denied the request and reported the services were not and are not medically for the treatment of this patient. At issue in this case is whether the 36 hours per week of direct 1-on-1 ABA services that the patient received from are medically necessary for the treatment of his medical condition. ABA services are being provided for this patient in the least restrictive setting, with an emphasis on generalizing to a more natural setting. The patient has made improvements since baseline as shown in scores on the Vin-3 assessment, and reports from the patients provider. Based on the Vin-3 assessment, the patient is still approximately two standard deviations below the mean. The patients goals will not be met and the level of interfering behavior will not be reduced if the intensity of care is reduced. Therefore, 36 hours per week of direct 1-on-1 ABA services that he received were and are medically necessary for treatment of this patients autism.Final Result: The reviewer determined that the requested services were and 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 psychologist and behavior analyst 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 parent of a 15-year-old female enrollee has requested blood tests, comprehensive stool analysis tests and urine porphyrins tests for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. Bloating, cramping, gas, bulky stools are symptoms that frequently accompanying fat malabsorption. Some of the causes of fat malabsorption include: biliary atresia, celiac disease and other food intolerances, certain medications, certain types of cancer, cholestasis, chronic liver disease, Crohns disease, radiation treatments, parasitic infection and Whipples disease. In this patients case, appropriate evaluation was conducted and no clinically significant findings were identified. Upon review of the medical records, the patients providers took appropriate steps to ensure completeness of evaluation and a rule out of significant pathology and such testing proved clinically unrevealing. In this setting, the standard of care is to consider diet modification as the next appropriate step if symptomatology persists. Based on the medical literature cited above and the documentation submitted for review, the requested testing is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the Zoll Life Vest (automatic external defibrillator vest) for medical treatment of her new onset heart failure.  Findings:  Two physician reviewers found that the patient does not meet the standard American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) criteria for an ICD, as she has a new diagnosis of non-ischemic cardiomyopathy. It is recommended to wait for a period of at least three months to optimize medical therapy before ICD placement. As the patient does not meet criteria for an ICD, she does not meet the criteria for the Life Vest device.