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

The parent of a 15-year-old male enrollee has requested 10 hours per week of direct applied behavioral analysis (ABA) (Code H2019) and 8 hours per month of supervision and parent training (Code H0032) for treatment of the enrollees autism.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Kelley et al). Additional studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey and Hastings). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh et al). The goals for older children often are to identify and remediate particular deficits.Although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. (Kelley et al). Treatments based on operant principles of learning were noted to be more effective for reducing problem behaviors displayed by individuals with intellectual disabilities and autism than were alternative treatments (Grey and Hastings). This patient has a diagnosis of autism and the behaviors in this patient to address include maladaptive behaviors of autism associated with communication, noncompliance, functional life skills as well as social and language skills. ABA therapy is medically necessary in this case. All told, the medical necessity of the requested services has been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for acupuncture services (12 sessions).Acupuncture is effective for the treatment of chronic musculoskeletal and osteoarthritis pain. A referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. In this patients case, she continues to be symptomatic despite treatment with physical therapy and medication. There is sufficient support for an acupuncture trial in this clinical setting. Three to six sessions are generally required to produce functional improvement. Therefore, an initial six sessions of acupuncture are medically necessary. Objective functional improvement should be established if additional treatment is requested. Significant objective improvement includes decreased pain, increased endurance, increased ability to perform activities of daily living, and improved sleep. Therefore, six sessions of acupuncture are medically necessary for the treatment of this patient. Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the left knee. Hyaluronic acids are naturally occurring connective tissues materials that help cushion and lubricate joints. Intra-articular injection of avian-derived or synthetic hyaluronic acids, or viscosupplementation, can decrease osteoarthritis symptoms in some patients. Guidelines do not recommend hyaluronic acids for patients with symptomatic osteoarthritis, based on strong evidence. The submitted clinical documentation does not support the use of viscosupplementation injections to treat the patients left knee osteoarthritis. Therefore, the requested Orthovisc injections for the left knee are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the requested Orthovisc injections for the left knee are not likely to be more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the requested Orthovisc injections for the left knee are not likely to be more beneficial for treatment of the patients condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic 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 patients parent has requested authorization and coverage for durable medical equipment - binaural behind the ear hearing aids. Findings:  The physician reviewer found that here is a lack of consensus on the criteria for hearing aid candidature and variability in the use of hearing aids in clinical practice among patients with mild hearing loss. In this patients case, the records document very mild hearing loss with 100% word recognition scores at 55 dB and 45 dB, and speech recognition thresholds of 25 dB and 15 dB in the right and left ears respectively. Given the lack of evidence in current medical literature of the benefits to be derived from hearing aids at this level of mild hearing loss, the requested equipment is not medically indicated. Therefore, durable medical equipment - binaural behind the ear hearing aids are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 otolaryngology 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 radiofrequency neurolysis. Findings:  Three physician reviewers found that the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature supports the utility of the proposed procedure in this clinical setting. Studies evaluated the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain. The authors review showed Level II evidence for long-term effectiveness of radiofrequency neurotomy in the lumbar and cervical spines, for facet joint nerve blocks in the cervical, thoracic, and lumbar spine. In this case, the patient has lumbar facet pain corroborated by history, physical exam and MRI. There is no evidence of nerve root compression on MRI. Therefore, the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested procedure 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 anesthesiology with sub-specialty certification in pain medicine 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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for Panzyga intravenous immunoglobulin (IVIG) 1 gm/kg over one day every two weeks. McGrath and colleagues noted that although corticosteroids are considered first-line therapy for anti-synthetase syndrome, IVIG is increasingly being used as initial therapy in patients with immune-mediating necrotizing myopathy. Kocoloski and colleagues reported that IVIG was associated with marked improvement in immune-mediated necrotizing myopathy patients, with 85% of patients meeting clinically significant response endpoints. Moreover, the authors found a substantial reduction in dose of prednisone required in patients treated with IVIG at six months. This patient was previously treated with IVIG with good results. The patient has also undergone treatment with multiple therapies without adequate response including methotrexate, hydrochloroquine, and rituximab. The patient was retreated with IVIG with a change in the administration. The medical literature supports treatment with IVIG as administered in this case to manage the patients anti-synthetase syndrome. Accordingly, Panzyga IVIG 1 gm/kg over one day every two weeks was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the Panzyga IVIG 1 gm/kg over one day every two weeks 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. In the medical literature, the largest studies reporting on the outcomes of multigene testing indicate that among female patients tested in clinical settings, about 5-10% have a BRCA1 or BRCA2 mutation, and about 4-7% have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may be associated with increased risks for these cancers. Panel testing is now considered a standard of care in this clinical setting. This patient has three close relatives with malignancies that could be familial and suspicious for a BRCA mutation on the paternal side. This meets the National Comprehensive Cancer Network (NCCN) guidelines for BRCA testing. Panel testing is now considered within the standard of care. Accordingly, the genetic testing genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in genetics and is actively practicing. One Reviewer is board certified in genetics and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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 33-year-old female enrollee has requested for a PET/CT scan for evaluation of her papillary carcinoma of the thyroid. Findings:  The physician reviewer found that in the setting of papillary thyroid cancer, PET/CT is most useful when the I-131 scan is negative and there is biochemical evidence of recurrent or persistent disease. PET/CT can detect recurrent cancer with a sensitivity from 68% to 98% and has been shown to have a significant impact on clinical management. This patient has had a somewhat complicated history of metastatic papillary thyroid cancer and is carefully followed by her clinician. PET/CT scan was clinically appropriate and can be particularly helpful in managing patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

The guardian of a seven-year-old female has requested  speech therapy and occupational therapy for treatment of her autism. Findings:  The physician reviewer found that fundamental to the diagnosis of an autism spectrum disorder (ASD) are deficits in speech and language. Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. For older, higher-functioning children who master basic elements of language, focused training in social uses of communication is often necessary. (Volkmar).Children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate.  This patient demonstrated significant delays in auditory comprehension and expression communication. Speech therapy is therefore medically necessary and appropriate for this patient.Children on the autistic spectrum typically have difficulties with fine and gross motor skills, motor planning and praxis, and sensory processing. The evaluation did not demonstrate significant deficits in any of these areas.. Therefore, occupational therapy is not medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcatheter valve repair of mitral regurgitation for treatment of his medical condition.   Three physician reviewers found that this patient had both symptoms and objective findings supportive of severe mitral regurgitation.  In addition, there is documentation that that patient had prohibitively high surgical risk due to severe left ventricular dysfunction.  Valve morphology on echocardiography was determined to be suitable for percutaneous valve repair using MitraClip device.  In this circumstance, percutaneous valve repair has shown to be a safe and effective alternative compared to open surgical repair for reducing mitral regurgitation.  There is sufficient support for percutaneous repair with MitraClip for patients with prohibitively high-risk for open surgical repair and suitable valve morphology.  Therefore, transcatheter valve repair of mitral regurgitation was likely to have been superior over other treatment options.  Final Result:  Three 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: One reviewer is board certified in internal medicine with sub-specialty certification in interventional cardiology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for more than one hour per day of skilled nursing care at home (up to 24 hours per day) for treatment of the enrollees chronic respiratory failure, severe sepsis with acute organ dysfunction, and tracheostomy. Findings:  The physician reviewer found that for most patients, the demands of invasive ventilation are too difficult to manage at home, and nursing home placement results. For patients who choose to stop invasive ventilation, symptoms of dyspnea, anxiety, and distress should be anticipated and treated. According to the available documentation, this patient should currently be receiving at least one hour of in-home skilled nursing services which should be adequate to handle ventilation, suctioning, and tracheostomy care, which are considered skilled nursing services. However, administration of medications, feeding, grooming, bathing, toileting and turning the patient, are considered custodial in nature and do not require in-home skilled nursing services. In addition, the records document that the patients current needs are met and the requested additional in-home skilled nursing services could substitute for her current care needs as a matter of convenience and to relieve the primary caregiver, but are not medically necessary. Moreover, the patient was stable at her most recent evaluation with her provider. For these reasons, more than one hour per day of skilled nursing care at home (up to 24 hours per day) is not supported as 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 internal medicine with sub-specialty certification in hospice and palliative 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: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested the X-stop procedure for treatment of his low back and bilateral leg pain.   Findings:  Three physician reviewers found that the X-Stop device is designed to distract the posterior elements of the stenotic segment and place it in flexion to treat neurogenic claudication.  These devices continue to be evaluated in clinical trials. Early results suggest a possible role in the management of degenerative disorders of the lumbar spine. In the study evaluating the device, the primary indications were age of at least 50 years, lower extremity pain with or without back pain that was relieved with flexion forward bending, and the ability to walk at least 50 feet. However, FDA documents released before a public hearing on the product raise concerns that the X-stop's effectiveness decreases over time. According to the FDA, it appears that the X-stop is only effective for a brief period and then begins to decline. While this patient has severe low back pain, as well as bilateral radial leg pain, there is insufficient evidence that the implantation of the X-stop device would be more efficacious than standard therapy in the treatment of this patients medical condition. Based on the scientific evidence available at this time, the X-stop device is not likely to provide greater relief for this patient than non-operative therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old female who has a history of morbid obesity with a body mass index (BMI) of 48.5. She has several comorbid conditions including gastroesophageal reflux disease, low back pain, and shortness of breath. Although the patient reports she has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery, the findings from the evaluation have not been provided. The Health Plan has authorized Roux-en-Y gastric bypass for the patient. However, she believes gastric bypass with duodenal switch is more appropriate in her case. A review of the published data shows that the duodenal switch procedure is superior to other surgical procedures, not only in terms of percentage of excess body weight loss (EBWL), but also from a quality of life perspective. Roux-en-Y gastric bypass is associated with a failure rate of more than 30% in three to five years, with a reported maximum EBWL of 60% to 70%. The duodenal switch procedure has a higher success rate and its efficacy is well established. As such, the requested procedure should be authorized. Prior to surgery it should be confirmed that the patient has obtained psychological clearance for weight loss surgery. For the reasons stated above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.