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

The parent of a 6-year-old female enrollee requested sensory integration therapy for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the patient has significant fine motor and sensory processing delays. Occupational therapy incorporating sensory integration therapy is a medically reasonable and appropriate modality to address these issues. All told, sensory integration therapy was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the capsule endoscopy for evaluation of the enrollees bladder problems and abdominal pain. Findings:  Two physician reviewers found that current American Society for Gastrointestinal Endoscopy guidelines for endoscopy in IBD recommend the use of capsule endoscopy in the diagnosis of Crohns disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohns disease even if imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful. In these studies, capsule endoscopy has proven more sensitive in the detection of small bowel Crohns disease than the alternatives such as computed tomography scan, small bowel follow-through, and enteroclysis. Capsule endoscopy resulted in a change in management in a significant number of patients based on findings missed by other tests. A recent study reported that capsule endoscopy has sensitivity of 89.6 percent and specificity of 100 percent for Crohns disease. Regarding the need for upper endoscopy in patients with suspected Crohns disease, American Society for Gastrointestinal Endoscopy guidelines for endoscopy in inflammatory bowel disease recommend capsule endoscopy as the next step after colonoscopy, and only recommend upper endoscopy before capsule endoscopy in pediatric patients. Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation 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 internal medicine with sub-specialty certification in gastroenterology 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 orthotics. The Health Plan has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees metatarsalgia of the right foot. At issue in this case is whether the requested orthotics are medically necessary for treatment of the enrollees medical condition.Researchers concluded that manufacturing custom-made orthotics for metatarsalgia has been shown to produce good functional improvement, patients satisfaction and subjective ratings of improvement (pain, surface of the symptomatic area) after two years of usage. The progress notes advise that the patient demonstrates foot pain with a diagnosis of metatarsalgia and plantar fasciitis. Orthotics are the standard of care for the treatment of both plantar fasciitis and metatarsalgia. Orthotics correct biomechanical abnormalities, which cause both plantar fasciitis and metatarsalgia. Orthotics correct the malposition of the foot allowing for reduction in foot pain. Therefore, the requested orthotics are medically necessary to treat the enrollees medical condition.Final Result: The reviewer determined that the requested devices 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 podiatry 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 63-year-old male enrollee has requested a thigh lift as well as excision of excessive buttock and back skin for treatment of his excess skin. Findings:  The physician reviewer found that in the absence of skin conditions, this pattern and severity of excess skin should not interfere with activities of daily living for this patient.  There is no documentation of a physical examination describing a skin condition related to the excess skin or office visits for treatment of such a skin condition in the reviewed records.  A thigh buttock lift or belt lipectomy lifts the thighs and buttocks by removing a circumferential segment of skin at the belt level. It is basically an abdominoplasty that is extended around to the back so the incision ends meet. The submitted photographs show little or no excess back skin, so the proposed procedure is the second half of a belt lipectomy and is primarily designed to lift the thighs.  Based upon the photographs, the patients condition does not constitute an abnormal structure of the body.  All told, the requested thigh lift as well as excision of excessive buttock and back skin is not reconstructive in nature and is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested Botox injections to the left knee for the treatment of her knee pain. Findings:  Three physician reviewers found that the requested services are not likely to be superior over other available treatment modalities.  This patient continues to have knee pain following lateral meniscal repair and plica excision.  Physical therapy and cortisone injections have not been beneficial.  Per the current medical evidence, cortisone injections have been shown to provide short-term benefits for intra-articular knee pain.  However, the effectiveness of Botox injections in this clinical setting has not been established by the current medical literature.  The use of Botox injections in this setting has not been well-studied.  All told, the requested Botox injections are not likely to be of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested a knee Dynasplint system for treatment of his knee contracture.  Findings:  Two physician reviewers found that there are some published case reports and case series related to the use of low-load prolonged-duration dynamic orthoses, such as the Dynasplint, for various joints.  However, there is a lack of high-grade data in the published, peer-reviewed, medical literature supporting the efficacy of the Dynasplint for chronic knee contractures.  Steffen and Mollinger showed no improvement in knee contractures treated with low-load prolonged stretch in a series of 28 subjects with chronic bilateral knee contractures (lacking at least 10 degrees from full extension), using one affected knee in each subject as the untreated control.  There is a lack of published high-grade data establishing that the requested knee Dynasplint system is more effective than a rigorous stretching and exercise program combined with appropriate analgesics and palliative modalities.  There is a lack of published high-grade data establishing that it is an effective adjunct to a basic exercise and modality program. It would not be anticipated to significantly impact the need for any potential future surgeries.  Overall, the requested equipment has not been proven to be effective for this patients condition.  While the patient does not have full range of motion at the left knee, it is not anticipated that the requested equipment would provide marginally significant improvements in outcomes compared to his present program. Thus, the requested knee Dynasplint system is not likely to be more efficacious than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heartburn surgery (transoral incisionless fundoplication (TIF) procedure with EsophyX device). Findings:  The physician reviewers found that TIF is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference. TIF can be performed in patients with typical GERD symptoms without or with low-grade erosive esophagitis, and a small hiatal hernia 2 cm or less. Although TIF is associated with fewer postoperative adverse effects such as gas bloating and dysphagia compared with surgical fundoplication, the durability of TIF has not been demonstrated in randomized, controlled, clinical trials. In addition, this patients records do not include objective documentation of acid reflux with a pH study or combined pH/impedance study. For these reasons, the requested heartburn surgery (transoral incisionless fundoplication (TIF) procedure with EsophyX device) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested heartburn surgery (transoral incisionless fundoplication (TIF) procedure with EsophyX device) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: A 56-year-old female enrollee has requested authorization and coverage for a power wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees stroke.The submitted documentation does not support the medical necessity of the requested equipment. A study by Punt and colleagues reported that people with neglect tend to have more difficulty navigating obstacles when using mobility equipment than those without neglect. A new power wheelchair device was not recommended by the evaluating physical therapist for mobility post stroke as the patient can ambulate without a device. The patient has demonstrated the ability to ambulate independently and did not demonstrate the ability to safely control the power wheelchair due to left neglect and vision impairment. Therefore, the requested power wheelchair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 physical medicine and rehabilitation 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 reimbursement and prospective authorization and coverage for physical therapy and occupational therapy at a skilled nursing facility (SNF). The records provided for review document that this patient presents with recent right-sided hemiparesis, difficulty walking, and hypertensive heart failure. The patient was admitted to a SNF and has been treated with physical therapy and occupational therapy. Hemiparesis is usually caused by stroke, but other potential causes include post-ictal hemiparesis, hemiplegic migraine, and psychiatric disorders (Fernandes, et al.; Terrin, et al.). The available charts indicate that by the date of denial, the patient made progress sufficient for community reintegration with home health services and custodial level assistance for management of her right-sided weakness with an unspecified etiology. There is a lack of support for ongoing physical therapy or occupational therapy services in the SNF treatment setting after the date of denial. By this date, the patient was a candidate for an alternative custodial level caregiver to assist her in the community. Therefore, the physical therapy and occupational therapy services at a SNF were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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

A 23-year-old male enrollee requested a continuous glucose monitoring system (Medtronic Pump E0784, A9277, A9276, and 530G system for medical treatment of the enrollees type I diabetes mellitus. Findings:  Three physician reviewers found that this patient has been unable to optimize his glycemic control despite diligent management of insulin pump therapy. Due to his inability to improve his diabetic control, he has experienced complications from diabetes, such as diabetic retinopathy. By using the recommended CGM system, he should be able to improve his glycemic control and prevent worsening of his diabetic complications. For these reasons, the requested CGM system (Medtronic Pump E0784, A9277, A9276, and 530G system) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested treatment with potential extrapleural pneumonectomy to include the use of intraoperative heated chemotherapy with the agent Gemzar/gemcitabine HCl for treatment of his malignant mesothelioma.  Findings:  The physician reviewer found that the medical necessity of the requested services has not been established by the submitted documentation. Although this patient has favorable histology (epithelioid type), lymph node disease predicts worse outcomes. Current guidelines suggest that pleurectomy/decortication when possible is preferred over extrapleural pneumonectomy.  Additionally, there is limited data supporting intraoperative heated chemotherapy in this clinical scenario.  All told, there is an absence of data for the heated intraoperative chemotherapy, and pleurectomy/decortication is medically appropriate and is preferred over extrapleural pneumonectomy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested canaloplasty for the left eye for treatment of her open-angle glaucoma.  Findings:  Two physician reviewers found that although penetrating glaucoma surgery continues to evolve, Filippopoulos and Rhee recommend reservation of surgical intervention for patients who have failed pharmacologic treatment and/or laser trabeculoplasty. Cheng and colleagues found that canaloplasty was associated with fewer complications than trabeculectomy. Thus, the use of canaloplasty may offer this patient superior health benefits when compared with standard therapy. As such, the requested canaloplasty is medically appropriate for treatment of this patients open angle glaucoma applying the current standards of practice and likely to be more beneficial for treatment of her condition than any standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing (CPT 81201, 81211, 8120, 81235, 81270, 8127, 81292, 81295, 81298, 81321) provided on 10/11/16.  Findings:  The physician reviewer found that recent literature explains that there is a risk of Richters transformation where the CLL may progress to more aggressive large cell lymphoma. Many combinations of chemotherapies and newer agents have been shown to have a response in CLL but none have clearly demonstrated an improvement in overall survival, according to the CLL Trialists Collaborative Group. The patient has exhibited potential resistance to therapy and mutational analysis was indicated. The Foundation Heme test analyzes over 400 oncogenes and tumor suppressor genes for mutations that may be amenable to targeted therapies. This is particularly important for those that have progressed on standard regimens. Molecular genetics can help guide therapy decision making, including evaluation for clinical trial. The use of molecular profiling such as with FoundationOne testing is likely to be more beneficial than any available standard therapy.  Final Result: Two of the 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/QualificationsAll three reviewers are board certified in medical oncology 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

The parent of a 12-year-old male enrollee has requested 86 hours per month of direct intervention applied behavioral analysis (ABA) therapy and 10 hours per month of program supervision as well as continued services for treatment of the enrollees autism. Findings:  The physician reviewer found that while continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. The medical literature supports the reduction of ABA hours to be replaced by school attendance and group social activities as the child ages. A study by Reichow and Volkmar indicates that ABA therapy directed toward specific maladaptive behaviors may be effective in the older child. In this patients case, ABA therapy is medically necessary and should be specifically directed toward interruption of his maladaptive behavior of smelling his food and tasting from others plates. The 20 hours per month of direct ABA therapy and 2 hours per month of supervision is reasonable and appropriate in this clinical setting. Given that the patient has had several years of ABA therapy, more than 2 hours per month of supervision is not medically necessary. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for targeted genomic sequence analysis panel (CPT 81450) provided by Neogenomics Laboratories. Based on the available documentation, this patient is suspected of having myelodysplastic syndrome (MDS). The National Comprehensive Cancer Network (NCCN) guidelines recommend that bone marrow or peripheral blood cells be assayed for MDS-associated gene mutations using gene panels. These gene mutations can establish the presence of clonal hematopoiesis, which can help exclude benign causes of cytopenias in cases with non-diagnostic morphology, but do not establish a diagnosis of MDS in the absence of clinical diagnostic criteria. The Neogenomics panel used for this patient included the recommended panel of tests per the NCCN guidelines. Given this support, the targeted genomic sequence analysis panel (CPT 81450) provided by Neogenomics Laboratories was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the targeted genomic sequence analysis panel (CPT 81450) provided by Neogenomics Laboratories was likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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.