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

This case concerns a seven-year-old female who was denied coverage for growth hormone (GH) therapy for short stature.  The patient had severe intra-uterine growth retardation (IUGR), weighing only three pounds eleven ounces at full term.  She failed to undergo catch-up growth by two years of age and demonstrated poor muscle tone with weakness and hypotonia.  The patient had hip dysplasia and treatment for clubfeet. She was also treated for wheezy bronchitis.  The patient is relatively obese, and has a mother who weighs 200 pounds and a paternal grandmother with diabetes.  Her pediatric endocrinologist predicted an adult height of less than 59 inches, which, based on mean parental heights, is more than two standard deviations below her target height.  The patient had a bone age of five years and six months in October of 2004, as compared to her chronological age of six years and four months.  In August of 2004 she had normal thyroid tests, a normal IGF-1 level at 82, and a normal IGFBP-3 level at 2.6.  The latter two results do not suggest a growth hormone deficiency.There appears to be some misunderstanding about the term IUGR in the record. This term has the same meaning as small for gestational age (SGA). SGA is an indication for GH therapy, provided the patient was born SGA, as defined by a birth weight or length equal to or greater than two standard deviations below the mean for gestational age, and fails to manifest catch-up growth from birth through age three, defined as a height equal to or greater than two standard deviations below the mean for age and sex. In this instance, the patient meets these criteria; as such, growth hormone therapy should be authorized. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an intravenous immunoglobulin (IVIG) infusion for treatment of her medical condition.  Findings:  The physician reviewer found that this patients records lack findings to support a diagnosis of chronic inflammatory demyelinating polyneuropathy  (CIDP).  Specifically, there are no significant clinical findings to support this diagnosis. The patients electromyography (EMG) was interpreted as normal and an EMG study alone is inadequate to evaluate for CIDP.  The standard work-up includes a spinal fluid analysis looking for elevated protein. Further, the records do not demonstrate a paraneoplastic etiology since the patient has no evidence of cancer as her lesions were biopsied and proven to be benign. The diagnosis of neuropathy was based on the finding of an abnormal anti-GD1a antibody which is a specific ganglioside that has been associated with an acute sensorimotor neuropathies in the Guillain Barre family. However, a study by Johannis and colleagues shows a poor predictive value using ganglioside testing for neuropathy as there are a high number of false positives. Further, Claudie and colleagues suggested that there is poor standardization among laboratories in testing for these antibodies. Overall, the patients positive anti-GD1a result is likely not clinically significant and there is a lack of evidence of an autoimmune neuropathy, paraneoplastic neuropathy, or CIDP.  Given these findings, the requested IVIG infusion 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 and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronan) injection in both knees.An 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. The current evidence is limited, and 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 patients options are limited. The patient has tried physical therapy and multiple corticosteroid treatments, with limited relief. The patients alternative is bilateral total knee arthroplasties for mild osteoarthritis of both knees. Therefore, Synvisc-One (hyaluronan) injection in both knees is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a blood pressure monitor for treatment of his medical condition. Findings:  The physician reviewer found that based on the records provided for review the patient presents with essential hypertension and no documented subjective symptoms or objective findings to support malignant hypertension or end organ damage as a result of hypertension. In this circumstance of essential hypertension without malignant features or evidence of end organ damage home blood pressure monitoring is not medically necessary. Regular blood pressure checks with the patients provider is medically reasonable and should be sufficient in the ongoing evaluation and management of the patients essential hypertension. All told, the requested blood pressure monitor is not medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in cardiovascular 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: Overturned

A 36-year-old male enrollee has requested a power seat lift, articulating leg rests, power reclining seat, and related accessories for treatment of his Beckers progressive muscular dystrophy. Findings:  The physician reviewer found that in the medical literature, Emery discusses Beckers muscular dystrophy as a genetic disorder characterized by a slowly progressive generalized weakness. The author further notes that some patients may experience a very mild disease course and maintain ambulation for prolonged periods of time, if not indefinitely, while other patients may have a more severe disease progression. In patients with more severe disease progression, a power wheelchair is required for mobility. In addition, activities should be encouraged and stretching may be needed to prevent contractures. In the present case, the patient has insufficient body strength to perform an independent lateral transfer. A power elevating seat would provide significant benefit for this patient by facilitating these independent transfers. The power seat is beneficial from the standpoint of reducing dependency and for the purpose of exercise. Similarly, the power reclining function and power articulating leg rests are appropriate for allowing the patient to stretch, reduce contractures, and to minimize edema and pain. For these reasons, the requested wheelchair features are medically necessary for this patient and should be approved.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile outpatient cardiac telemetry (MCOT) (CPT 93229). This patient has low risk of a life threatening arrhythmia based on age, the prolonged length of her symptoms, and no prior cardiac history or family history of sudden death or congenital arrhythmias. Current guidelines generally recommend external automated loop recorders for patients with infrequent syncope and the use MCOT real time monitoring for patients with syncope and a high likelihood of life-threatening arrhythmias requiring immediate action or attention. This patient has experienced infrequent episodes and the records do not include documentation of prior investigations for arrhythmia. Therefore, the use of real time monitoring with MCOT, as opposed to an external automated loop recorder, would not be an appropriate initial diagnostic test in the detection of a possible arrhythmia causing these isolated episodes. This is especially true in a patient who is at low risk for life-threatening arrhythmias that would require immediate real time interventions. All told, the MCOT (CPT 93229) was not 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 MCOT (CPT 93229) was 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 services at issue were not likely to be more beneficial for evaluation of the patients medical 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 internal medicine with subspecialty certification in cardiovascular disease 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgery.Findings:  The physician reviewer found that the World Professional Association for Transgender Health (WPATH) is clear in stating that facial feminization surgery is a medically necessary treatment for gender dysphoria. The WPATH states that facial feminization surgery for some patients is a more necessary surgery than genital surgery and that the medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The WPATH states that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition (WPATH 2016). Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like vaginoplasty, is associated with improved mental health-related quality of life in transgender women (Ainsworth and Spiegel, 2010).In this case, there is substantial documented evidence of the medical necessity of surgery for this patient, including a mental health assessment that establishes that the patient presently has clinically significant distress and functional impairment from Gender Dysphoria. The patients providers have noted that she reports significant distress, anxiety, and depression when seeing pictures or reflections of her face, and that her goals of surgery are to alleviate dysphoria, and to align her outward appearance with her true gender identification. Under these circumstances, the requested facial feminization surgeries are medically necessary to treat 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 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 has requested authorization and coverage for esketamine (Spravato) nasal spray. This patient carries a documented diagnosis of major depressive disorder, recurrent severe, without psychosis. Moreover, the patient meets the definition of treatment resistant major depressive disorder due to failure of medical therapies including high-dose Paxil 40 mg and Lexapro. He has also had multiple trials of sufficient duration with Wellbutrin. Currently, he is on Viibryd 40 mg daily in addition to Wellbutrin XL 300 mg daily and BuSpar 5 mg three times a day. He is currently on the maximum dose of Viibryd, and has undergone a sufficient trial of medication and Wellbutrin. Wellbutrin should not be further increased due to its influence via 2D6 on Viibryd levels, which could elevate his risk of serotonin syndrome, especially since he is also on a stimulant and BuSpar. The patient reports that his depression has worsened over the past year and he is unable to get out of bed. The patients depressive symptoms are causing him extreme distress and his occupational functioning is now severe. Researchers noted that a variety of antidepressant treatments are available for the treatment of major depressive disorder, but may patients fail to achieve sustained symptomatic remission. Authors concluded that the results of their study consistently showed a clinically relevant, favorable improvement in depressive symptoms with esketamine (either 56 mg or 84 mg) nasal spray plus a newly initiated antidepressant. On review of the medical literature and this patients clinical history, the patient meets the criteria for treatment resistant depression. His clinical condition is severe and the rapid benefits of Spravato in alleviating his depression is appropriate. All told, the requested Esketamine (Spravato) nasal spray is medically necessary for this patient. 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 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

The parent of a nine-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  Three physician reviewers found that ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorders (Dawson, et al.; Rogers, et al.; and Warren, et al.).  The scientific literature supports the use of ABA. Treatments based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. A recent 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism specific behaviors using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles (Dawson, et al.). Warren, et al. reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches, early intensive behavioral intervention variants and the Early Start Denver Model resulted in improvement in cognitive performance, language skills, and adaptive behavior skills. Additional studies have shown treatment using ABA therapy to be efficacious (Rogers, et al.). ABA offers a program that is intensive, structured, and individualized with explicit teaching of social skills, communication and learning to learn skills (National Research Council). In sum, the ABA services at issue were and are likely to be more efficacious than any other therapy for treatment of the patients autism.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested Botox injections for the treatment of her jaw pain status post traumatic injury. Findings:  Three physician reviewers found that Botox works by paralysis of the muscle tissue. The theory behind its use in patients with TMD is that it will decrease muscle tonicity and relax overactive muscles associated with the TMJ to alleviate hyperactive muscle pain and tension on the TMJ. The National Institute of Dental and Craniofacial Research assert that Botox is not approved by the U.S. Food and Drug Administration (FDA) for TMD and studies are currently ongoing. Further, Botox is not discussed in detail in these recommendations, rather the lack of medical literature proving the safety of Botox for this condition was addressed. Ultimately, the scientific data does not support Botox as an established therapy for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement for residential treatment center services for treatment of his medical condition. Findings:  The physician reviewer found that Based on the documentation submitted for review, residential treatment center services were not medically necessary for treatment of the patients medical condition. Residential treatment is utilized for acute stabilization and is not supported for long-term type treatment. The evidence based literature indicates that psychiatric symptoms must be severe and present to the degree for residential treatment level of care is needed. In this case, the records do not indicate severe psychiatric symptoms were present prior to his admission or during his stay. Per the American Academy of Child and Adolescent Psychiatry Child and Adolescent Level of Care Utilization System (CALOCUS), the patients symptoms and environment correlates with a treatment intensity level of three which correlates with intensive outpatient services. The patient had some risk of harm due to episodic outbursts, however he was not having active suicidal ideation. His function status was moderate as he had minimal school disruption and able to complete his activities of daily living in an age appropriate manner. He had no active serious medical problems and has a stable housing situation. His family is actively involved in treatment and attend family therapy sessions on a regular basis. Moreover, the patient participates actively in therapy, but has poor insight. Based on the records submitted for review, the patient had stabilized sufficiently to allow transition to a less restrictive setting during the dates in dispute. 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 sub-specialty certification 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: Upheld

A 36-year-old male enrollee requested chiropractic services for medical treatment of his medical condition.  Findings:  The physician reviewer found that the patient presented for treatment of low back pain which began while lifting weights.  However, the records do not document an examination or evaluation to the lumbar spine which is essential for diagnosing this patient.  The assessments do not discuss the low back, but note medial high ankle sprain and Achilles strain.  In this patients case, there is a lack of documentation regarding the lumbar spine in the office visits to support the services at issue.  All told, chiropractic services were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 Functional electrical stimulator (FES) (HCPCS code E1399). The records document this patient has a history of right cerebrovascular accident (CVA) on in 2016 with hemiparesis. After a CVA, patients with resulting hemiparesis experience impaired use of upper extremities and impaired gait. Although some evidence suggests that FES cycling training can improve lower extremity motor functions and accelerate the recovery of overground locomotion in post-acute hemiparetic patients, there is a paucity of data that supports use of FES cycling for upper extremity motor recovery. Overall, there is a lack of high quality research demonstrating that FES cycling provides more benefit or better outcomes than standard therapy to improve posture or bone density or general fitness level in post-stroke rehabilitation. Therefore, the requested RT300 FES (HCPCS code E1399) is not 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 requested RT300 FES (HCPCS code E1399) 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 equipment 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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.