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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for sacroiliac (SI) joint surgery.Findings: Two out of three physician reviewers found that the SI joint surgery is likely to be more beneficial for you than any available standard therapy.SI joint syndrome is one common reason for persistent chronic low back pain. If conservative treatments fail to improve symptoms, arthrodesis surgery can be considered. Minimally invasive approaches have recently emerged, providing a better alternative to conventional methods. A triangular implant system can be used without need for bone grafting or screw fixation to achieve an optimal fusion of the SI joint. Minimally invasive surgical arthrodesis of the SI joint is known to result in significant improvement in pain and function. Moreover, a study by Rainov and colleagues found that, SI joint fusion with triangular titanium implants produces significant improvement in pain and disability related to SI joint dysfunction. In this case, the patients right SI joint is known to be the source of pain. This was confirmed with two SI joint injections with associated excellent short-term pain relief. Additionally, the patient has failed conservative treatment. Therefore, the requested SI joint surgery is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in orthopedic surgery. All reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for allergen specific IgG testing. As noted in the medical literature, IgG allergy testing may be indicated for patients with an allergic reaction to determine a possible etiology for their symptoms. However, this patient does not have allergy-type symptoms reported in the records provided for review. All told, the allergen specific IgG testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy. Findings:  Three physician reviewers found the allergen specific IgG testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy.Final Result: The reviewers determined that the allergen specific IgG testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification 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 17-year-old female enrollee has requested for residential treatment care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is no indication of the patients risk to self or others during the time period in question. National guidelines indicate that residential treatment is a specific level of care, distinguished by 24-hour therapeutically planned behavioral health intervention along with highly supervised and structured group living. Individualized therapies and related services should be provided by a multidisciplinary team of clinically licensed professionals including psychiatrists, psychologists, social workers, nurses, special education teachers, activity therapists, and others. Lastly, national practice guidelines indicate that patients with major depression should be treated in the most appropriate level of care which is likely to be safe and effective.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested mental health intensive outpatient program services for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that this patient has substantial academic and social dysfunction.  It is unlikely that an ongoing individual therapy at this time will show marked improvement in these areas without the containment of a more enhanced program.  Therefore, mental health intensive outpatient program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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

The parent of a 17-year-old female enrollee has requested adolescent psychiatric intensive outpatient program for the treatment of the enrollees panic disorder with agoraphobia. Findings:  The physician reviewer found that the services at issue involve an intensive outpatient program involving exposure-based interventions. Connolly and colleagues review of the clinical literature suggests that exposure-based cognitive behavioral therapy (CBT) has substantial empirical support for the treatment of anxiety disorders in young patients. In fact, the authors state that early assessment and intervention are crucial, as are evaluation of co-morbid disorders, and analysis of severity and impairment. Modification of standard CBT for treatment of patients with panic disorder includes interoceptive exposure and education about the physiological process that leads to physical sensations like dizziness, shortness of breath, and sweating. The American Academy of Child and Adolescent Psychiatry (AACAP) discusses more than 30 publications, mostly case reports, which demonstrated the clinical benefits of exposure-based interventions for pediatric patients with OCD. Also, component analyses of CBT suggest that both exposure and response prevention are active ingredients of treatment. Exposure is believed to reduce phobic anxiety, while response prevention reduces the performance of rituals. Clinicians assess the patients obsessions and compulsions, contamination fears, symmetry rituals, counting, and hoarding to select the appropriate CBT strategy. Thus, clinicians who are trained and experienced in applying these techniques achieve the best results. After careful review of the evidence-based publications, I have concluded that intensive outpatient program treatment for this patient was and is medically indicated. This young patients symptoms are disabling and impair her ability to function in daily life. Further, she was being treated at a lesser level of care but her panic disorder persisted.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male has requested 40 hours per week of applied behavioral analysis (ABA) therapy (behavioral intensive early intervention program) and 4 hours per week of supervision for treatment of autism.   Findings:  The physician reviewer found that applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A recent retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning autism spectrum disorder. The authors found that 62% of children in the optimal outcome group received intensive behavioral therapy (greater than 20 hours per week) whereas only 13% of the high-functioning group received this level of intervention (Kelley, et al.).Treatment intensity appears to play an important role in clinical outcomes. According to Granpeesheh and colleagues, ABA therapy must be implemented at a sufficient intensity (40 hours per week) in order to provide optimal outcomes. The authors studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. They concluded that the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours per week. In light of this patients young age and documented deficits, the proposed regimen of 40 hours per week of direct ABA therapy and 4 hours per week of supervision is medically appropriate and necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center (RTC) services for treatment of his medical condition.  Findings:  The physician reviewer found that the patient was initially showing withdrawal symptoms. He was manic, paranoid, delusional, and grandiose. Although not overtly endorsing suicidal or homicidal ideation, his initial actions on top of his impaired mental state due to use of methamphetamine constituted a potential danger to him and others. For this reason he was initially unsafe to be treated at a lower level of care. He required time for the acute psychotogenic effect of the methamphetamine to defervesce before he was safe for treatment at a lower level of care. All told, the initial RTC services were medically necessary and the subsequent RTC services at issue were not medically necessary for treatment of this patients medical condition.   Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:   The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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

A male enrollee requested Harvoni 90-400 mg for 12 weeks for medical treatment of his chronic hepatitis C virus genotype 4.   Findings:  Three physician reviewers found that patients with genotype 4 are recommended to be treated with Harvoni for 12 weeks. These new guideline recommendations are based on the SYNERGY trial, an open-label study evaluating 12 weeks of ledipasvir/sofosbuvir in 21 hepatitis C virus genotype 4 infected patients who were either treatment-naive or had advanced fibrosis (Kapoor, et al). Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Harvoni 90-400 mg for 12 weeks is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 15-year-old male with gynecomastia. According to the record he is not having pain or other physiologic problems related to his breast enlargement. He is said to suffer from low self-esteem, but there is no record of psychological counseling or psychotherapy included for review. The patients parent has requested authorization for bilateral reduction mammoplasty. The request was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The record indicates the patient is obese, and obesity is a well-recognized cause of pubertal gynecomastia. According to Georgiadis, et al idiopathic gynecomastia is closely correlated with generalized obesity and reduced LH and testosterone levels which may be the result of increased conversion of testosterone to estradiol in increased adipose tissue mass. Weight loss is likely to improve this condition. The literature further indicates that gynecomastia generally resolves by age 18 when adult hormonal balance is achieved. Lazala and Saenger recommend delaying surgical intervention until puberty is completed, or nearly completed. The American Society of Plastic Surgeons (ASPS) reports that gynecomastia occurs in 38% of males ages 10 to 16 years. The ASPS attributes physiologic gynecomastia to an altered estrogen/androgen balance or to an increased sensitivity of breast tissue to a normal estrogen level and indicates that 90% of all cases will resolve spontaneously within three years. Where there is a pathological etiology for the gynecomastia such as obesity, the ASPS guidelines recommend six months of medical treatment prior to surgery. In this instance, the records do not document any medically supervised attempts at weight loss. Although reduction mammoplasty may seem appropriate from an aesthetic standpoint, a more conservative treatment approach focusing on weight loss and a waiting period for the patient to progress through puberty may accomplish the same goal and make the surgery unnecessary.  Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for a positron emission tomography (PET) scan for evaluation of the enrollees newly diagnosed leiomyosarcoma. Findings:  Two physician reviewers found that patients who have underwent routine hysterectomy with the incidental finding of uterine sarcoma such as in this case, the National Comprehensive Cancer Network (NCCN) recommend that those patients have CT scans of the chest, abdomen, pelvis or abdominal/pelvic magnetic resonance imaging (MRI) and chest CT to evaluate for metastases. For patients who have had their tumors morcellated such as in this case, the NCCN indicate that pelvic MRI should be considered. The NCCN further states that PET/CT scanning should be considered for ambiguous findings. Considering the propensity for leiomyosarcomas to metastasize distally, it is reasonable to obtain one imaging study that can image the entire body. As noted by the NCCN, to adequately stage this patient, separate CT or MRI studies would have to be performed for every anatomic region. According to research In a staging procedure, whole body FDG PET/CT discloses the presence of both local recurrence and remote metastases at widespread musculocutaneous sites, liver, and femur. With its advantage of scanning the whole body in a single procedure, we propose the use of PET/CT imaging for the evaluation of patients with uterine leiomyosarcomas, a tumor with propensity for widespread hematongenous spread to unusual sites. Further, peritoneal implants are not at all unusual in these patients (similar to ovarian cancer).  Peritoneal implants can be very difficult to detect at an early stage on routine CT scanning. In this case, there was no initial indication that the patients suspected fibroid would turn out to be a leiomyosarcoma. For this reason, the surgery performed did not adequately stage the patient. Nodal sampling was not performed, and clear margins cannot be evaluated. Final Result: The reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in diagnostic radiology 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 30-year-old female enrollee has requested inpatient cognitive rehabilitation for treatment of her traumatic brain injury.  Findings:  The physician reviewer found that at this time, there is a lack of consensus or supporting data demonstrating that the increased intensity offered by an inpatient cognitive rehabilitation program mid-course in an individuals recovery results in meaningful gains sustained beyond six months. Rehabilitation after brain injury, traumatic or otherwise, is very much tied to the brain's recovery. As the brain recovers rehabilitation sustains and maximizes the recovery. If the brain does not regain function, continued rehabilitation does not change the outcome. Given the patients injury, she will need a sustained rehabilitation program. She is independent in many of her functional activities but needs supervision and cuing. While it is reasonable and appropriate for the patient to participate in a sustained program of cognitive rehabilitation, there is no evidence to support the requested inpatient cognitive rehabilitation as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee requested inpatient hospitalization stay for medical treatment of the enrollees ulcerative colitis flare-up.  Findings:  The physician reviewer found that the patient was admitted with a diagnosis of an acute exacerbation of ulcerative colitis (UC). She had failed outpatient treatment with oral steroids. Upon admission she was treated with IV steroids and antibiotics and did improve. During her hospitalization her labs improved and she remained afebrile. She was tolerating an oral diet and had non-bloody stools. For the management of severe UC, Peppercorn and Farrell state, In patients who respond, intravenous glucocorticoids should be converted to equivalent dose of oral glucocorticoids in three to five days. The patient was treated appropriately and remained stable. She could have been converted to oral steroids and  discharged.  Based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested artificial cervical disc replacement for the treatment of her degenerative cervical disc disease and neck pain status. Findings:  Three physician reviewers found that the patient has no radicular nor myelopathic symptoms. She has no neurologic abnormalities nor symptoms nor findings on exam.  She has axial neck pain, which is a contra-indication for cervical disc arthroplasty, as addressed by the above referenced author, and discussed in much of the available medical literature. Furthermore, her pain has been in her lower neck, yet surgery has been proposed on her upper/mid neck. Thus, based on this patients clinical findings, there is inadequate evidence that artificial disc replacement is likely to be efficacious.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.Findings:  Two physician reviewers found that  the patient has breasts that have been described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: The patient is a 33-year-old male who was diagnosed with chronic hepatitis C. Laboratory results dated 10/20/18 revealed the patients viral load was 1,450,000 IU/mL. On 2/28/19, the provider noted the patient was diagnosed with hepatitis C, genotype 3 infection in October 2018, and he has never been treated for hepatitis C. On 2/28/19, serum fibrosis testing was consistent with F0, lack of fibrosis. The patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan denied the requested and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Mavyret for eight weeks is medically necessary for the treatment of the patients medical condition. The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend treatment for all patients diagnosed with chronic hepatitis C virus (HCV) infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines support an eight-week regimen of Mavyret for the treatment of non-cirrhotic, treatment-naive, genotype 3 patients. Testing for nonstructural protein 5A (NS5A) resistance variants is not recommended. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment with Mavyret in treatment-naive, non-cirrhotic, genotype 3 patients with chronic HCV (Foster, et al.). The medical evidence supports the requested medication in this clinical setting. Therefore, Mavyret 100 mg-40 mg for eight weeks is medically necessary for the treatment of 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 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.