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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for genetic testing, whole exome (CPT codes 81404, 81405, 81406, 81407, 81408, and 81479). The records provided for review indicate that this patient likely has an underlying connective tissue disorder, the most typical of which is hypermobile Ehlers-Danlos syndrome. A diagnosis of hypermobile Ehlers-Danlos syndrome is made clinically and does not require genetic testing. However, according to the providers evaluation, the patients clinical picture is multisystemic in nature. Given the potential overlap with other forms of Ehlers-Danlos syndrome, the provider recommended a connective tissue sequencing panel. The clinical implications of diagnosing subtypes of Ehlers-Danlos syndrome merit vigilant surveillance (Chu, et al.; Frank, et al.). Thus, next generation sequencing for vascular Ehlers-Danlos syndrome and related disorders (CPT 81408) is appropriate for this patient. Thus, genetic testing CPT code 81408 is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found genetic testing CPT code 81408 is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an automated blood pressure monitor for treatment of the enrollees medical condition. Findings:  The physician reviewer found that This patient has had frequent monitoring of his blood pressure and heart rate in an office setting, and these values are mostly controlled with an occasional mild elevation in blood pressure.  Ambulatory blood pressure monitoring is indicated with suspected white coat hypertension, suspected episodic hypertension, hypertension resistant to medications, hypotensive symptoms while taking blood pressure medications and autonomic dysfunction.  Automated blood pressure monitors are not generally indicated for the evaluation of patients with uncomplicated hypertension or to screen for hypertension.  In this case, the documentation supports that the patient is receiving treatment for his blood pressure and is having frequent monitoring of blood pressure and heart rate in a clinical setting.  The measurements taken indicated controlled hypertension.  The patient does not have complications with end-organ disease.  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 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 metaxalone 800 mg tablet, one tablet twice per day #60/30 days. This patient presents with multiple joint pain, memory lapses, and excessive sleep. Treatment has included baclofen, carisoprodol, cyclobenzaprine, tizanidine, and methocarbamol with adverse effects or ineffectiveness. The medical records demonstrate an allergy to Flexeril, baclofen, and methocarbamol. The patients current medications include Dibucaine, loratadine, metoclopramide, Skelaxin, and Voltaren 1% topical gel. The patient reports chronic pain as well as side effects of excessive sleep and memory lapses. Shaheed and colleagues performed a systematic review to evaluate the use of muscle relaxants for the treatment of low back pain. The authors found that muscle relaxants, such as metaxalone, may be helpful for short-term acute low back pain but not for chronic low back pain. The authors noted that, there is limited evidence of their clinical efficacy and tolerability. This patient has been on metaxalone for longer than six months for chronic joint pain. The records fail to demonstrate evidence of significant pain reduction or functional improvement. Moreover, the medical literature does not support long-term use of metaxalone. For these reasons, the requested metaxalone 800 mg tablet, one tablet twice per day #60/30 days, is not medically necessary for treatment of this patient.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 with subspecialty certifications in allergy and immunology and rheumatology 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: Upheld

A 53-year-old male enrollee has requested coronary CT angiography (CTA) for the evaluation of his cardiovascular status. Findings:  Three physician reviewers found that CTA is not, thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CT angiography cannot accurately confirm or exclude important coronary artery obstructions. The use of CTA in the diagnosis and prognosis of coronary artery disease or the assessment of by-pass graft patency, is an experimental/ investigational application of the technology.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter pylori antibody testing. Findings: Three physician reviewers found that the diagnosis of Helicobacter pylori infection can be achieved in several ways, including endoscopic evaluation, histology, urea breath testing, bacterial culture from biopsy specimens, serology, and stool antigen testing. Each method has its advantages and disadvantages, and several methods are often used to confirm or exclude the diagnosis. Routine screening of asymptomatic patients with serology is not recommended. In this case, the patient had no symptoms to suggest the presence of Helicobacter pylori. Therefore, the services at issue were not indicated based on the records provided. In sum, Helicobacter pylori antibody testing was not likely to have been of greater benefit than other methods of evaluating this patient. 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 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 enrollee is requesting authorization and coverage for H.P. Acthar gel injections. The enrollee has multiple sclerosis. The medical records report the enrollee has experienced severe acute, debilitating exacerbations of this disease, negatively impacting his physical and mental health and quality of life. The enrollee has experienced worsening fatigue, heat intolerance, decreased range of motion in the right foot, decreased tone of the right lower extremities, and diminished deep sensation in the right upper extremities. He has failed to respond to conventional therapies, including Tysabri, Avonex, and dalfampridine. The enrollee has a contraindication for corticosteroids. Research shows adrenocorticotropic hormone has additional immunomodulatory benefits, apart from its stimulation of endogenous corticosteroid release.  A researcher reports there is renewed and appropriate interest in using this decades-old therapy for multiple sclerosis and other inflammatory disorders.  Adrenocorticotropic hormone remains Food and Drug Administration-approved for multiple sclerosis exacerbations; new studies indicate possible additional benefits over corticosteroids.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy. There is increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. A four month IVIG trial should be considered in severely affected patients who are refractory to lifestyle and pharmacological therapies. Antiphospholipid antibodies and novel Sjogren antibodies are often present in these patients and correlate with a high response rate to IVIG. The clinical improvement with immunotherapy in these patients correlated with markedly improved findings on autonomic testing in all. There is increasing evidence that immunomodulation with IVIG is helpful in treating patients with autonomic dysfunction and Sjogren syndrome. These studies are small and there are no national guidelines to recommend this therapy. In this case, the medical records provided fail to demonstrate a diagnosis of Sjogren syndrome and confirm the diagnosis of peripheral neuropathy. The medical records demonstrate normal thyroid studies, normal complete blood count, normal renal panel and normal/negative rheumatoid factor. There is a presumed diagnosis of Sjogren syndrome, mast cell activation and POTS. The records provided fail to demonstrate a diagnosis of Sjogren syndrome. As such, the request for intravenous immunoglobulin (IVIG) therapy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested treatment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plan denial should be upheld.Credentials/Qualifications: The reviewer is board certified in allergy and immunology and internal medicine with subspecialty certification in rheumatology 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 authorization and coverage for revision of bilateral breast augmentation.At issue is whether a revision of bilateral breast augmentation is medically necessary to treat the enrollees gender dysphoria as defined in Health and Safety Code section 1374.72(a)(3)(A).World Professional Association for Transgender Health (WPATH) lists feminizing mammoplasty as a treatment for gender dysphoria. WPATHs Position Statement on Medical Necessity of Treatment states, Non-genital surgical procedures are routinely performed notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH also conclude, These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. However, in this case, the patient has already received a breast augmentation in 2020, with good results. There is no documentation that larger implants are indicated or medically necessary. In this patients case, the requested revision of bilateral breast augmentation is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the requested revision of bilateral breast augmentation is not medically necessary for treatment of the patients medical condition. 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 psychiatry with expertise in transgender 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

The parent of a 2-year-old female enrollee requested (1) 30 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy; (2) 3 hours per week of ABA parent training; (3) 6 hours per week of ABA supervision; (4) 2 hours per week of occupational therapy; and (5) 2 hours per week of speech therapy for medical reatment of the enrollees autism spectrum disorder (ASD), developmental delay and developmental speech and language delay.  Findings:  The physician reviewer found that based on the documentation submitted for review, the request for 30 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy, 3 hours per week of ABA parent training and 6 hours per week of ABA supervision is medically necessary for treatment of the patients ASD. Applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Granpeesheh, et al; Kelley, et al).  Speech therapy at the frequency of 2 hours per week is medically necessary in this clinical setting. This patient presents with ASD and a history of expressive and receptive language delays with socialization and pragmatic deficits. Language deficits are one of the core aspects of autism; speech therapy provides professional help and guidance on communication development for individuals with autism. Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Volkmar and Wiesner). The request for occupational therapy (OT) at the frequency of 2 hours per week is not clinically indicated. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks or activities of daily living (Baranek). In this case, the patient presents with age-appropriate fine motor skills.   I have determined that a portion of the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tymlos pen injector. Findings: According to the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE), Tymlos is considered an anabolic agent that has been shown in randomized controlled clinical trials to increase bone mineral density and reduce the risk of vertebral and nonvertebral fractures in patients with osteoporosis. Tymlos has been approved by the U.S. Food and Drug Administration (FDA) for the initial treatment of women with postmenopausal osteoporosis who are at high-risk of fracture or have failed or been intolerant of previous osteoporosis therapy. In this case, the patient has demonstrated a progressive worsening of T scores on DEXA scans over a period of several years despite prior therapy with alendronate and zoledronic acid. According to the AACE and ACE guideline, Tymlos is supported for treatment of patients who have failed previous osteoporosis therapy. Given this support, the requested Tymlos pen injector is medically necessary for 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 rheumatology 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 two-year-old male enrollee has requested physical therapy, at a frequency of one 30 minute session per week, and occupational therapy services, at a frequency of one 60 minute consultation per month for treatment of the enrollees developmental delays.  Findings:  The physician reviewer found that occupational therapy (OT) and physical therapy (PT) are utilized to improve the patients abilities to adapt and function in activities of daily living and gross motor skills development. With this degree of fine and gross motor impairment, this patient has a medical necessity for OT and PT services.  Myers, et al., points out the success of rehabilitative therapies in preschool children, enabling transition into a school setting.  According to Schaaf, et al., sensory integration techniques utilized by the occupational therapist, aids the developmentally delayed child to develop the ability to integrate into normal feeding and personal-social patterns to function with his peers. Additionally, improvements in behavior patterns have been noted in patients who have been treated by OT, utilizing sensory integration techniques. In sum, the requested services are medically necessary for treatment of this patients medical condition. The patient should be reassessed at six month intervals to determine if continued treatment is indicated..
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee has requested authorization and coverage for eye movement desensitization and reprocessing (EMDR) for two hours per day for 90 days, or at any frequency or duration, cognitive behavioral therapy (CBT) twice per week, or at any frequency and duration, and residential treatment center (RTC) level of care with dual diagnosis. In review and consideration of additional documentation provided, the requested services including EMDR for two hours per day for 90 days, or at any frequency or duration, CBT twice per week, or at any frequency and duration, and RTC level of care with dual diagnosis are not medically necessary for treatment of this patients behavioral health issues. There is no new information to show that the patients condition warrants these treatment interventions. The patient is not documented to be a danger to herself or others, or demonstrate emotional, behavioral, or cognitive factors necessitating residential level of care. The patient has been medically stable. She had demonstrated the ability to maintain an extended period of sobriety while travelling between two states, and attending meetings and having sponsors in both states, showing motivation for sobriety. The patient has a history of extensive residential and IOP levels of care, as well as extensive EMDR and DBT. Her Clinical Institute Withdrawal Assessment (CIWA score was 3, with mild symptoms of non-observable tremors, mild anxiety, and agitation was 1. There were no subjective or objective findings of post-traumatic stress disorder (PTSD) symptoms including severity which would substantiate the request for EMDR or CBT. The patients presentation supports treatment at the ambulatory level of care with the aid of ongoing AA and her sponsor. All told, the requested EMDR for two hours per day for 90 days, or at any frequency or duration, CBT twice per week, or at any frequency and duration, and RTC level of care with dual diagnosis, are not medically necessary for treatment of this patients behavioral health issues.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old male enrollee has requested substance abuse residential treatment services for treatment of his alcohol dependence.  Findings:  The physician reviewer found that although the patients family history is significant for alcohol dependence, his personal patterns of abuse are unclear. It does not appear that a structured outpatient program was attempted prior to admission. The admission examination does not suggest symptoms of physical withdrawal or any other particular distress that would require 24-hour supervision. The patient could have been appropriately treated at an outpatient level of care.