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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) supervision services for treatment of the enrollees autism spectrum disorder. Findings: The physician reviewer found that the request for of ABA supervision services have been established as medically necessary for treatment of the patients autism. In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior and ABA services can be utilized to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism. Therefore, ABA therapy supervision services are medically necessary for treatment of the patients medical condition.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 with special qualification in child 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: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient spent approximately three months in the wilderness program and immediately thereafter was admitted to the residential program at issue. When she left the wilderness program, she was not afforded an opportunity for treatment at a lesser level of care. Thus, she could not have been considered refractory to a lesser level of treatment because such care had not been provided. Her course in the residential facility showed some variation in behavior, but at no time did she become suicidal, homicidal, or psychotic. Her interactions with peers and staff were occasionally problematic but were not of such severity as to require residential care. At no time during her admission did her clinical state necessitate the need for care at a residential level. Residential treatment was not medically necessary because the patient could have been safely and effectively treated at a lesser level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for plantar hyperhidrosis surgery for treatment of the enrollees plantar hyperhidrosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In recent years, lumbar sympathectomies have been proposed for treatment of patients with intractable plantar hyperhidrosis. To date, the amount of long-term, prospective evidence addressing the use of lumbar sympathectomy for the treatment of plantar hyperhidrosis is extremely limited. Questions about efficacy, side effects and long-term outcomes have yet to be answered.  Since a formal protocol/technique does not yet exist for this novel technique, the level at which surgeons perform the lumbar sympathectomy is controversial and may vary among institutions.  For this reason, higher rates of complications are associated with lumbar sympathectomies than alternative treatments for hyperhidrosis. At this time, the medical evidence addressing the use of lumbar sympathectomy is insufficient to allow an adequate evaluation of safety and efficacy.  All told, the requested plantar hyperhidrosis surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld

The parent of a 34-year-old male enrollee has requested a comprehensive skin biopsy karyotype for an evaluation of his medical condition. Findings:  The physician reviewer found that there are no cures for Down Syndrome, either typical or Mosaic. Therefore, treatment for the condition focuses on controlling symptoms and any medical conditions that may occur as identified. No specific screening is indicated as a consequence of Down Syndrome. Genetic testing and/or providing a definitive diagnosis does not improve the medical management of the patient, nor does it lead to treatment opportunities which would result in improved functionality. Genetic testing to prove or disprove the existence of Mosaic Down Syndrome is thus not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested the second session per week of outpatient psychiatric services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that the patients treatment goals, current assessments of functioning, specific plans for therapy and considerations for treatment termination were not delineated by the provider. All told, the patients current request for coverage of additional one-hour weekly therapy sessions provided since the date in question does not meet the criteria in the generally accepted practice guidelines as medically necessary (Gelenberg, et al). Further, applying the Level of Care Utilization System (LOCUS) recommendations as discussed by Sowers and colleagues, the frequency or duration of the desired outpatient therapy was not medically necessary or required for a safe and timely achievement of this patients treatment goals based upon the records provided for review. As such, this patients records fail to support the medical necessity of additional outpatient psychotherapy visits at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for MHTFR gene testing.Findings: Three of the three physician reviewers found that the MHTFR gene testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The American College of Medical Genetics (ACMG) recommends against testing anyone for MTHFR variants, including those with a known family history of polymorphisms, as there is no clinical utility in such testing. In fact, MTHFR testing was included in the ACMGs recent list of tests not to order as part of the Choosing wisely campaign. There is no known treatment recommended for those who have 1 or 2 copies of these polymorphisms. Therefore, the MHTFR gene testing performed for the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Three of the three reviewers determined that the MHTFR gene testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: One reviewer is board certified in genetics and clinical biochemical genetics and is actively practicing. One Reviewer is board certified in genetics and is actively practicing. One Reviewer is board certified in genetics 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for left eye corneal collagen cross-linking procedure and the riboflavin 5-phosphate ophthalmic solution, up to 3 mL. Corneal cross-linking is a U.S. Food and Drug Administration (FDA) approved procedure for keratoconus and post-refractive ectasia. The primary purpose of cross-linking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. This patient meets the criteria for corneal cross-linking with documented evidence of progressive keratoconus. Therefore, the left eye corneal collagen cross-linking procedure and the riboflavin 5-phosphate ophthalmic solution, up to 3 mL 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 that the left eye corneal collagen cross-linking procedure and the riboflavin 5-phosphate ophthalmic solution, up to 3 mL 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 ophthalmology 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

A 59-year-old male enrollee has requested Crestor 20mg for treatment of his hyperlipidemia and peripheral vascular disease. Findings: The physician reviewer found that in this circumstance, medical therapy for treatment of hyperlipidemia with an HMG-CoA reductase inhibitor is reasonable, appropriate, and considered standard accepted practice in the medical community. However, this patient has not had a trial of higher dose of the Health Plans preferred statin, Zocor, at 80 mg per day. As such, the patient has not demonstrated treatment failure to that regimen. In addition, there is no evidence of side effects to any of the preferred formulary statins. Moreover, the patients records do not document increased risk of intolerance such as a history of rhabdomyolysis, advanced age, uncontrolled hypothyroidism, or renal impairment. Since the Health Plans preferred statin, Zocor has been shown to improve cardiac outcome and there is no evidence of incremental outcome benefit with Zocor at similar lipid levels, the use of Crestor at this time is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested Celebrex for treatment of his low back pain.  Findings:  The physician reviewer found that this patient has severe Crohns disease.  Non-selective COX inhibitors can cause significant risks in Crohns patients, such as risk of flare up, gastrointestinal bleeding, and delayed healing or remission times.  In this case, the primary physician and surgeon have provided adequate support for the use of Celebrex in this clinical scenario.  The medical literature has shown much lower relative risk and odds ratios for upper and lower gastrointestinal effects overall, and decreased risk for patients with Crohns disease using Celebrex and other COX-2 specific inhibitors. All told, Celebrex is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of a consultation with a neurologist who specializes in epilepsy. The Health Plan denied the request indicating that requested services are not medically necessary for treatment of the enrollees seizures.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old female with a history of chronic migraine headaches. She is currently taking Topamax, Flexeril, and Seroquel. The patient has also been diagnosed with bipolar disorder. The submitted records do not document the current number or severity of the patients headaches. The patient also has a history of neck pain and surgery, but there is no documentation regarding any current neck problems except as mentioned in the patients request for authorization of Actiq. The Health Plan has determined Actiq is not medically necessary for treatment of the patients condition.It is likely this patients headaches are associated with medication overuse secondary to daily narcotics. The records provided do not demonstrate the patient has had a thorough trial of a variety of preventative medications. Thus, it appears that the patient has not explored usual and customary modalities for the treatment of mixed migraine and chronic daily headaches including narcotic detoxification. As such, use of Actiq is not medically warranted for this patient.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female has requested authorization and coverage for a continuous glucose monitoring machine for the treatment of her diabetes mellitus. Findings:  The physician reviewer found that the majority of insulin pump patients use continuous glucose monitoring systems episodically in order to change their insulin prescription because they have not reached their glycemic goal or are having frequent unexplained hypoglycemia or hyperglycemia. This is particularly important for patients who have hypoglycemia unawareness. In these situations, several 72 or more hour readings may be needed several times a year. More frequent continuous glucose monitoring would not be medically necessary for most patients. This patient is likely to benefit from using the continuous glucose monitoring machine two to four times per year for a few weeks.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested authorization and coverage of injectable Forteo. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested transcatheter MitraClip repair for treatment of his medical condition.  Findings:  Two physician reviewers found that the transcatheter MitraClip repair performed was not likely to be more beneficial for treatment of the patients medical condition than available standard modalities. The medical literature does not support a definitive opinion or evidence based data supporting sustained benefit and improved long term outcomes associated with this procedure at this time. Two authors performed a literature review to evaluate whether there are any indication criteria, process, and structural requirements, or scientific society and institutional guidelines for the use of the MitraClip System. The authors concluded that The MitraClip System is a promising procedure, but evidence-based indication criteria, structural, and process requirements for its use are lacking. Further results from prospective, randomized controlled trials are needed to determine patients, potential adverse events, device durability, and long-term follow-up. Based on the lack of support in the literature, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were 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:  All three reviewers are board certified 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xolair 300 mg administered every two weeks in the providers office. The records provided for review document that this patients medical history is significant for allergic rhinitis and severe persistent asthma. The patient has been treated with combination therapy consisting of inhaled corticosteroids and long-acting beta-agonists with fluticasone furoate and vilanterol. Severe asthma warrants aggressive and phenotype-specific management. The patients provider recommended anti-IgE biologic therapy with Xolair based on the allergic phenotype of his asthma, which resulted in significant improvement in asthma control. Xolair is U.S. Food and Drug Administration (FDA) approved for allergic-type asthma in patients who have failed combination inhaled corticosteroids and long-acting beta-agonists. Given the risk of serious allergic reaction, the standard of care is to give the injection in the providers office to enable monitoring of side effects. Treatment with Xolair is within the standard of care for the management of asthma in this patient. Therefore, the requested Xolair 300 mg administered every two weeks in the providers office is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested osteochondral allograft surgery for treatment of his right knee osteochondritis.  Findings:  The physician reviewer found that  the management of osteochondral defects is complex with little high-level evidence to favor one procedure over another, although encouraging short-term and midterm outcomes have been reported with osteoarticular transplantation (Harris, et al). Osteochondral allograft transplantation offers the advantage of no limitation in the size of tissue available. Therefore, the procedure is an option in treating lesions of 2 cm or larger, although disease transmission and rejection are justifiable concerns (Carter, et al). Timing of the procedure is also of concern, since chondrocyte death has been reported 2 to 3 weeks after procurement of the graft, and it is unclear whether duration of allograft storage affects the clinical results (McAdams, et al). Proper positioning has also been shown to be a factor of great importance in graft survival (DLima, et al). The importance of patient selection has also been emphasized, with the need for the absence of significant articular cartilage defects (McCulloch, et al). There is a paucity of prospective, randomized controlled clinical trials comparing the different techniques and options (Simon and Jackson). Further studies are needed to determine whether cartilage surgery can yield better functional outcomes than other treatment (Loken, et al). In this case, the presence of osteoarthritis has been noted. In addition, the arthroscopic evaluation of the joint was based on photographs of the initial procedure which may not be an accurate evaluation of the present status of the knee. There is no documentation of any conservative measures employed to treat the patient, or the results of that treatment. For these reasons, the medical necessity of the requested osteochondral allograft surgery has not been demonstrated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronic acid injections of the right knee. Findings:  The physician reviewer found that exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has tried cortisone injections, a knee brace, restriction of activities, and medications, without significant long-term relief. The patients options are limited, with the alternative being a total knee arthroplasty. The patient also has metastatic lung cancer and does not wish to undergo surgery. In light of the patients underlying medical conditions, surgery is not medically recommended. The current medical evidence supports the requested services in this clinical setting. Therefore, the requested hyaluronic acid injections of the right 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.