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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for visual communication analysis (VCA). As noted in the medical literature, visual communication analysis has not been systematically evaluated and demonstrated to provide improved patient outcomes as compared to standard available therapies. In the medical literature, Borowiak and colleagues found that this patient population did not respond to visual-movement or gestures during speech. Overall, the findings suggest that visual communication strategies are not substantially helpful. Applied behavioral analysis (ABA) has a large research base showing efficacy to treat the core symptoms of autism including communication, aggression and other behaviors. Visual communication analysis is not the standard of care treatment for autism. Accordingly, the requested visual communication analysis 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 visual communication analysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested visual communication analysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in pediatrics 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services on an emergent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention. According to High and colleagues Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous adverse reactions, most commonly triggered by medications, characterized by fever and extensive necrosis and detachment of the epidermis. SJS and TEN are considered a disease continuum and are distinguished chiefly by severity. Upon review of the submitted medical records, the patient presented with persistent fever despite being on antibiotics, recurrent dehydration and worsening rash thought to be due to medications. Each of these conditions were potentially life threatening and in the absence of immediate medical attention could reasonably be expected to result placing the patients health in serious jeopardy, Therefore, the services met prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for out-of-network services received. The services on 03/31/17 do not meet criteria for an emergency medical condition. The patient's symptoms were not sudden or acute in onset. She was not in severe pain. The patient had already been evaluated by a podiatrist and had undergone x-ray imaging. She had not sustained any new or recent trauma. Symptoms of the gradual onset of a painless bump on an extremity do not meet criteria for an emergency medical condition. The services provided on 7/19/17 meet criteria for an emergency medical condition. The patient was a contact lens wearer who had developed superficial punctate keratitis. She had been placed on topical medications and advised she needed follow-up exam. On the date in question, the patient was still symptomatic. Since keratitis may cause permanent vision loss, it was medically prudent for the patient to have a repeat eye exam. Persistent symptoms of keratitis would be considered an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services on 7/19/17. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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 40 hours per week of one-to-one applied behavior analysis (ABA) therapy, four hours per week of case management and one hour per week of parent training. The submitted documentation supports the medical necessity of the requested services. ABA therapy has been identified as the most evidence-based treatment for patients with autism. The Behavior Analyst Certification Board (BACB) notes that patients with autism spectrum disorder who have deficits across multiple skill domains that jeopardize health or safety should receive comprehensive ABA interventions at high intensity. Although 40 hours or more is commonly recommended for younger children, the BACB indicates that comprehensive interventions may also be appropriate for older patients with autism spectrum disorder who exhibit severe deficits or behavioral excesses across environments. A direct assessment of the complexity, severity, and nature of individual needs should be used to determine the scope and quantity of ABA interventions. In this patients case, the records document a variety of complex medical, behavioral, and developmental needs that require ongoing intensive intervention. Specifically, the patient presents with deficits in functioning that are substantially below age level and problematic behaviors that continue to require careful monitoring and intervention. Therefore, 40 hours per week of one-to-one applied behavior analysis (ABA) therapy, four hours per week of case management and one hour per week of parent training are medically necessary for the treatment of this patient. 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 board certified behavior analyst and licensed psychologist 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for breast cancer (CPT codes 81211, 81213, and 81321).  Findings:  Three physician reviewers found that this patient has a personal history of breast and endometrial cancer and meets criteria for panel genetic testing on several levels. She meets National Comprehensive Cancer Network (NCCN) criteria for BRCA testing based on a personal history of breast cancer and a family history of a close relative with pancreatic cancer. She meets NCCN criteria for testing for Li-Fraumeni with several relatives with brain cancer on the same side of the family. In addition, she meets NCCN criteria for testing for Lynch syndrome given a personal history of both breast and endometrial cancer and a close relative with pancreatic cancer and brain cancer. Panel testing is now considered standard of care. In sum, genetic testing for breast cancer (CPT codes 81211, 81213, and 81321) was likely to have been more efficacious than other methods of evaluating this patient. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for excess skin removal surgery. Findings:  The physician reviewer found that The medical records note significant weight loss following bariatric surgery.  The patient is documented to have evidence of excess skin of the abdomen, breasts and buttocks.  However, the submitted photographs indicate that these conditions were mild.  Her functional problems included chronic rashes underneath skin folds and chronic neck pain.  With respect to conservative management of the rashes, she appears to have used a steroid cream and an antifungal agent.  Based on the entirety of the medical documentation and review of the photographs, the panniculectomy was medically necessary.  She had a lower abdominal pannus overhang.  She had chronic rashes that had failed reasonable conservative dermatologic treatment.  Although the degree of overhang is only mild based on the photographs, there are reports from multiple providers, including dermatology, that support her functional compromise and failed treatment.  This is not supported with the other areas of concern, including the breasts.  Based on the review of the photographs, the degree of ptosis and size of the breasts does not support that this is likely the source of her chronic neck pain.  There is some suggestion of a functional deficit related to chronic rashes underneath the breasts, but this has not been adequately detailed in the medical documentation provided, and the photographs do not support that this is likely as well. Based on the records provided, the patients condition does not constitute an abnormal structure of the body.  A review of the photographs depict relatively normal appearing structures of the breast, upper abdomen, thighs and buttocks/flanks.  There has not been adequate documentation that the planned procedures were provided to improve function.  The planned procedures would have created a possible cosmetic improvement. Final Result: The reviewer determined that a portion of the services at issue was 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 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment services for treatment of his behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients illness burden had necessitated three acute admissions in the preceding two months.  Further, an attempt at the intermediary setting of partial hospitalization was unsuccessful.  His alcoholism dominated his daily routine, negatively impacted his relationships and caused significant impairment across multiple domains of functionality.  His social and living environments as arranged were unable to support sober living.  Further, the patient had multiple co-occurring psychiatric conditions which compromised his prognosis.  Per the medical records, discharge would have been premature.  He was anxious, disruptive, irritable and isolative.  He was not adequately maintaining his activities of daily living.  He lacked the skills necessary to effectively manage conflict and struggled with self-disclosure.  In this patients case, in the absence of residential programming, he was likely to have promptly relapsed and required re-admission.  All told, residential treatment services were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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: Upheld

A 66-year-old male has requested proton beam radiation therapy for treatment of prostate cancer.  Findings:  The physician reviewer found that there is no convincing evidence that proton beam radiation therapy is superior to standard of care treatment in this setting such as surgery or others forms of external beam therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for positron emission tomography (PET) with concurrently acquired computed tomography for attenuation correction and anatomical localization imaging, whole body for evaluation of her colon cancer. Findings:  The physician reviewer found that The national Comprehensive Cancer Network (NCCN) guidelines regarding PET/CT for the work-up and management of invasive non-metastatic colon cancer indicate that Patients who present with invasive colon cancer appropriate for resection require a complete staging workup, including pathologic tissue review, total colonoscopy, a complete blood count, chemistry profile, carcinoembryonic antigen (CEA) determination, and baseline computed tomographic (CT) scans of the chest, abdomen, and pelvis. The consensus of the panel is that a positron emission tomography (PET)/CT scan is not routinely indicated at baseline, and should not be performed as a matter of general surveillance. Furthermore, a PET/CT scan does not obviate the need for a contrast-enhanced diagnostic CT scan. If abnormalities are seen on CT or MRI scan that are considered to be suspicious but inconclusive for metastases, then a PET/CT scan may be considered for further delineation of that abnormality, if such delineation will change management. A PET/CT scan is not indicated for assessment of sub-centimeter lesions, as these are routinely below the level of PET/CT detection. This position is also consistent with Centers for Medicare and Medicaid (CMS) guidelines as well as the American College of Radiology (ACR) appropriateness criteria for imaging. Additionally, Care Core National guidelines state that the routine use of PET or PET/CT is not recommended for the diagnosis and staging of clinical stage I-III colorectal cancer and may be used to evaluate individuals in whom there is metastatic disease and surgical resection for cure is planned. In this case, there is no indication that initial imaging has been performed and the patients CEA is negative. Thus the requested PET/CT scan is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested for laparoscopic gastric bypass surgery for treatment of her medical condition. Findings:  The physician reviewer found that studies have shown that long-term weight loss in class II is difficult to maintain, especially when physical activity is not possible or significantly limited, as is the case with this patient. It has been documented that there is a direct relationship between increasing BMI and relative risk of death.  There is no conservative method that will adequately treat this patients condition. Continued delay will expose her to grater risk of developing severe comorbidities. The 2004 ASBS Consensus has recommended bariatric surgery to patients who fall into this group who have a condition that can be cured or markedly improved by a substantial and sustained weight loss which can result from the operative procedure.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a thirteen-year-old female enrollee has requested for Humatrope for treatment of the enrollees condition. Findings:  The physician reviewer found that this patient with idiopathic short stature is destined not to reach a normal adult height.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested for a CT to detect coronary artery calcification (CT coronary calcium scoring) for evaluation of his high cholesterol. Findings:  Two physician reviewers found that according to the NCEP-ATP II Guidelines cited above, treatment is targeted at risk-factor management. These guidelines do not incorporate or recommend screening with CT coronary calcium scoring. No incremental outcomes benefit has been shown with CT coronary calcium scoring in a setting such as this, beyond that attainable by management based on clinical-risk profiling.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cabometyx tablet. Soft tissue sarcomas are a diverse group of cancers that comprise of over 50 different histologic subtypes. Alveolar soft part sarcoma is characterized by a pathognomonic translocation that can lead to the production of pro-angiogenic factors, which provides the basis for anti-angiogenic therapy. Sunitinib is a small molecule inhibitor of PDGFR, vascular endothelial growth factor (VEGF) among others. The records provided for review document that this patient progressed despite treatment with sunitinib. Given this progression, his provider has recommended treatment with Cabometyx, a multi-function tyrosine kinase inhibitor. Cabometyx has been FDA approved for progressive metastatic medullary thyroid cancer. In addition, at least two studies have shown activity of Cabometyx in the treatment of soft tissue sarcomas. Given this support, the requested Cabometyx tablet is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Cabometyx tablet is likely to be more beneficial for treatment of the patients medical condition than any available standard therapyFinal Result: The reviewers determined that the requested medication is 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/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine and subspecialty certifications in medical oncology and hematology 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: Overturned

The parent of a five-year-old female enrollee has requested authorization and coverage for speech therapy, two times per week for treatment of the enrollees apraxia of speech. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  Law and colleagues noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Verbal apraxia, or childhood apraxia of speech, involves impairment in planning and coordinating movements for speech production.  While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired.  This is a neurological disorder that requires intensive treatment.  If left untreated or inadequately treated, these children are at risk for reading and spelling problems in addition to the articulation problems.  Communication at all levels may ultimately be impaired.  In this patients case, she demonstrates speech and language deficits which are negatively impacting her ability to communicate in a functional and age-appropriate manner.  The literature supports the medical necessity of speech and language therapy in this clinical setting.  All told, the requested speech therapy, two times per week, is medically necessary for the treatment of this patient.