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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT codes 82172 and 83704) for evaluation of the enrollees hyperlipidemia. Findings:  The physician reviewers found that based on the documentation provided for review, the patient presents with some coronary risk including hyperlipidemia. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), lipid particle number, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the advanced lipoprotein testing (CPT codes 82172 and 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three 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 reviewer number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and actively practicing. The reviewer 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: Upheld

A 65-year-old female enrollee has requested vertebral axial decompression, physical medicine, electrical stimulation and application of low level laser therapy services for treatment of her chronic low back pain and sciatica.  Findings:  Two physician reviewers found that overall, the use of muscle stimulation for back pain and/or spondylolisthesis has not been widely reported to result in improved health outcomes beyond that achievable through conventional treatment modalities. Although there may be some transient improvements in pain, sustained long-term analgesic and functional gains above that expected from the natural history of waxing and waning of pain symptoms and function during the course of a chronic pain syndrome state have not been demonstrated in a scientifically rigorous manner. Further, there is no proven clinical benefit of low level laser therapy, including in the infrared spectrum, in back pain syndromes with respect to analgesic effects or functional outcomes versus placebo.  As noted by Bingol and colleagues, there was no significant improvement in pain, active range, and algometric sensitivity in the laser treatment group compared to the control group in patients with shoulder pain. A meta-analysis by Chou and colleagues similarly revealed limited evidence from one randomized controlled trial for the use of infrared laser for the treatment of acute neck pain and chronic neck pain. The authors concluded that larger studies are required to confirm the positive findings and determine the most effective laser parameters, sites and modes of application. With respect to the chiropractic manipulation under review, there is notably no proven sustained benefit in the peer-reviewed clinical literature of prolonged chiropractic manipulation on health or functional outcomes in the setting of low back pain. There is also inadequate data to support the efficacy of whole body vibration therapy. To date, there are preliminary data suggesting possible improvements in strength and jumping ability in sedentary or elderly patients exposed to this type of treatment. However, without any high-grade support in the scientific literature proving the efficacy of this device in the setting of back pain, it is not likely to be more effective than standard therapies (Cardinale and Pope). Moreover, observations from occupational medicine have demonstrated that prolonged exposure to [whole body vibration] can have major negative effects on health. All told, none of the treatments rendered and documented in the records reviewed are of proven benefit for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female has requested a wireless capsule endoscopy for evaluation of her stomach pain.  Findings:  Three physician reviewers found that the patient is under evaluation for right lower quadrant pain. She has had a prior appendectomy. The patient has had a previous upper endoscopy, colonoscopy and CT scan of the abdomen and pelvis which were normal. Specifically, the results of the CT scan indicated that the entire length of small bowel appeared normal without thickening or increase in luminal diameter. There is no mention of inflammatory changes surrounding the small bowel loops. Biopsies of the terminal ileum were negative for granulomas or evidence of chronic inflammation. Included in the submitted records are a CBC with differential, complete metabolic profile, and urine analysis which were normal. A transabdominal and transvaginal ultrasound of the pelvis was normal. The patients provider has recommended wireless capsule endoscopy.While wireless capsule endoscopy is more sensitive than a small bowel contrast study for detecting inflammatory bowel disease (IBD), the records provided do not demonstrate that a diagnosis of Crohns disease is likely in this case. Based upon the documentation provided, the pre-test probability of the presence of Crohns disease is extremely low. The patients CT scan indicated the small bowel was completely normal and there is no evidence of inflammatory changes, bowel wall edema or stenosis. Most patients will have abnormalities detected on regular CT that raise the issue of ileitis, especially if they have significant pain such as in this case. In the absence of compelling clinical information to suggest inflammatory bowel disease (beyond right lower quadrant pain), a wireless capsule endoscopy is an extremely low yield study to pursue and is not likely to be of greater benefit than standard diagnostic modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested a positron emission tomography (PET) study for an evaluation of her endometrial cancer of the uterus. Findings:  Three physician reviewers found that the patient is a 61-year-old female with surgically proven endometrial cancer with negative nodes upon pelvic lymph node dissection. The Health Plan has denied reimbursement for a PET scan, and the patient is appealing this denial. The patients Health Plan has clear guidelines for authorization and coverage for PET and CT scans. These guidelines are medically appropriate and do not list endometrial cancer as a diagnosis for which PET scans would be covered. The American Cancer Society describes PET imaging for endometrial cancer as needing further study and not routinely ordered. PET scan was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested platelet rich plasma injections for treatment of his medical condition.  Findings:  Three physician reviewers found that platelet rich plasma therapy has not been proven to be an effective treatment for chondral injury, chondral pathology, arthropathy, tendinopathy or bursitis affecting. There is a lack of high-grade clinical studies to support the efficacy of the autologous platelet rich plasma injections, specifically in the setting of any knee condition, including patellofemoral, patellar, or tibiofemoral pathology. There is a lack of evidence that it favorably modifies the clinical course of any musculoskeletal condition. Multiple reviews have concluded that there is a lack of high-grade evidence to support the efficacy of this intervention. Given the lack of high quality medical literature establishing the effectiveness of platelet rich plasma, 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: Three 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 physical medicine and rehabilitation 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

An enrollee has requested authorization and coverage for buttock liposuction. The submitted documentation fails to demonstrate the medical necessity of the requested services. Lipomas are generally treated with surgical excision because of the possibility of complete removal and minimal risk of recurrence. This patient had a recurrence of a lipoma after liposuction. The removal was possibly incomplete because of the presence of asymmetry post liposuction. Per the records, the provider recommended imaging prior to proceeding with surgery. The records do not document that this has been performed. The recommended MRI is appropriate prior to proceeding with the requested services. Therefore, the requested buttock liposuction is not medically necessary for the treatment of this patient. In this patients case, the patients condition constitutes an abnormal structure of the body. The lipoma is an abnormal structure of the body which is caused by a tumor. The records document an abnormal appearance. Additionally, the requested services will be performed to improve function and to create a normal appearance. The requested buttock liposuction is likely to provide more than a minimal improvement in the appearance of the patient. Therefore, the requested buttock liposuction is reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition but are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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 14-year-old female enrollee has requested speech therapy services for the treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the speech therapy records provided for this patient do not demonstrate that she has achieved specific or adequate functional gains. The reports show no changes or improvements in the goals listed. The treatment summary goals are identical for each date and do not demonstrate a change from one visit to the next. As such, there is a lack of evidence demonstrating that the patient has benefitted from speech therapy. Furthermore, a literature review by Pennington and colleagues concluded that Firm evidence of the positive effects of SLT [speech and language therapy] for children with cerebral palsy has not been demonstrated by this review. The authors further indicate that there is insufficient information on outcomes regarding the use of augmentative and alternative communication (AAC) systems in this setting. As such, additional speech therapy to improve the patients oral motor skills and/or to help facilitate use of the AAC device is not supported by peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested Subsys 400mcg for treatment of her chronic pain syndrome.   Findings:  The physician reviewer found that in this patient case the medical records submitted for review do not mention intolerance to Cymbalta or Lyrica. The medical records do not document the use of other short-acting narcotics such as morphine, oxymorphone, and hydromorphone, all of which are not FDA indicated solely for malignancy related pain and have been better studied for chronic non-malignant pain. The progress note on the specified date indicates in the review of systems section that the patient does not have abdominal pain, constipation, nausea, or vomiting. The sublingual route of opioid administration does not avoid the effect of mu-opioid agonists in the gastrointestinal tract, and Subsys does not have a purported better gastrointestinal tolerability than other opioids. Furthermore, Subsys creates a much faster rise in serum concentration levels than oral short-acting narcotics and therefore there may be greater potential for abuse (Parikh et al). Finally, there does not appear to be evidence of routine drug monitoring including urine drug testing documented in the submitted records. Since it does not appear that other short-acting narcotics have been trialed and there does not appear to be adequate screening for aberrant behaviors, the request for Subsys 400mcg is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested treatment for her post-traumatic stress disorder, chronic, major depressive disorder and reactive attachment disorder. Findings:  The physician reviewer found that an evidence-based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is appropriate for use in determining the necessary level of care in order to ensure the level of care meets the individuals needs at the least restrictive setting possible. Application of the CALOCUS criteria yields the following: 1) Risk of harm - significant, 2) Functional status - moderate, 3) Co-Morbidity - minor, 4A) Recovery environment, level of stress - moderate, 4B) Recovery environment, level of support - supportive, 5) Resiliency and treatment history - moderate, 6A) Acceptance and engagement, child/adolescent - constructive, 6B) Acceptance and engagement, parent - constructive. This results in a composite score of 20 which correlates with a treatment intensity level of four, or intensive integrated services without 24-hour psychiatric monitoring treatment. An example of this level of care would be transitional housing, shelters or a group home. As discussed above, the patient is not residing in a traditional residential treatment center, but rather is residing in a group home. Therefore, her current level of treatment is appropriately matched to her needs.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg-100 mg for 12 weeks for treatment of the enrollees 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, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found.  The current guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication regimen 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 patient has requested authorization and coverage for albendazole (400 mg) and ivermectin (200 mg) each daily for 28 days, then off for two weeks, then repeat this for two more cycles for a total of three cycles. In this case, the records do not document parasitic infection. Given that there are no pathologic specimens documenting a parasitic infection, the requested medications are not medically indicated. Therefore, albendazole (400 mg) and ivermectin (200 mg) each daily for 28 days, then off for two weeks, then repeat this for two more cycles for a total of three cycles are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 infectious 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Stelara (ustekinumab) 90 mg/mL injection every 12 weeks. Findings:  The physician reviewer found that the records document extensive, recalcitrant psoriasis.  He has tried and failed therapy with topical steroids, methotrexate, Enbrel and Humira. The patient was previously treated with Stelara 90 mg/mL injections, with excellent effect.  The patient has tried treatment with Stelara 45 mg/mL injections, and this has not maintained clearance. The medical evidence supports the requested medication dosage in this patients case.  The patient has already shown response to the requested dose and lack of response to the typical dose. Final Result: The reviewer determined that the requested medication dosage 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 dermatology 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

An enrollee has requested reimbursement for dental braces. The submitted documentation does not support the medical necessity of the services at issue. Colleagues have studied the relationship between malocclusion and quality of life in adolescents. Their study concluded that malocclusion and orthodontic treatment do not appear to affect general or oral health quality of life to a measurable degree. This is despite subjective and objective evidence for improved appearance, oral function and health and social well-being. To assess the need for orthodontic treatment, there are many objective tools to quantify the degree of handicap caused by the malocclusion. Orthodontic treatment need indices are used to rank the malocclusion. Colleagues have explained that these indices were devised to minimize the subjectivity associated with the diagnosis, referral and complexity assessment of malocclusion. One widely used tool is the Handicapping Labio-Lingual Deviation (HLD) Index. In this case, the HLD Index score computed by the treating orthodontist did not reach the threshold for severe malocclusion. In addition, the submitted records do not suggest there were issues with speech, swallowing or nutrition; nor is there a defined medical condition that would necessitate treatment. The records state that the patient has a slight open bite on the right side. The records do not demonstrate that this is a significant disability causing an impediment to normal chewing. The records indicate no demonstrated excessive malocclusion, mild crowding and some tooth rotations, and no excessive overjet or overbite. Under these circumstances, the dental braces provided to the patient were not medically necessary for treatment of the patients medical condition.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 dental 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive applied behavioral analysis (ABA) therapy per week. Colleagues evaluated 726 children ages 1.5 to 12 years receiving ABA therapy and reported that the patients demonstrated increased progress towards learning objectives with increased intensity of treatment. The authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. Additional studies of ABA in patients with autism have recommended at least or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from hours of treatment per week. This patients records document that she has made progress in many areas, but continues to demonstrate significant behavioral concerns. The patient continues to require a high level of support to transition appropriately. Failure to master these skills places the patient at an increased risk for injury and makes it increasingly difficult to be successful in more generalized environments. Given these findings, the request for continued coverage of intensive ABA therapy per week is medically necessary for treatment of this 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.