Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom foot orthotics for treatment of bilateral plantar fasciitis.  Findings:  The physician reviewer found that the submitted documentation supports the requested equipment in this clinical setting.  Evidence-based guidelines generally recommend orthotics devices for plantar fasciitis foot pain in rheumatoid arthritis, and plantar heel pain.  Guidelines state that outcomes from using a custom orthosis are highly variable and dependent on the skill of the fabricator and the material used.  A trial of a prefabricated orthosis is recommended in the acute phase, but due to diverse anatomical differences, many patients will require a custom orthosis for long-term pain control.  This patient presents with a diagnosis of bilateral plantar fasciitis.  Clinical examination findings documented a cavus foot with restricted range of motion and bilateral hallux valgus.  The records document a history of custom orthotic wear to treat her bilateral plantar fasciitis and high arches.  There is evidence-based medical guideline support for custom orthotic use for long-term pain control for plantar fasciitis foot pain.  All told, the requested custom foot orthotics are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for the prescription medication Aciphex for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. All PPIs are essentially equivalent in terms of healing control of intragastric pH over 24 hours. However, interpatient variability has been seen with PPIs. Milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested  residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment provided from the time frame specified was medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, as of the date indicated the patient had not developed true insight into the nature of his problems. At that time, the patient was still lacking appropriate coping skills to prevent him from relapsing both into substance abuse as well as to prevent him from engaging in antisocial behaviors. The patients therapist noted that the patient spent much of his time focused on saying what he believed his parents and others wanted to hear in hopes of being able to leave the facility after his assessment. Although the staff saw through his manipulations, his parents would not have been equipped to recognize and respond appropriately to this behavior. Thus, the patients home environment would not provide adequate support and a premature discharge would have likely caused the patient to regress back into his substance abuse and antisocial behaviors. As such, the medical necessity of the treatment provided has been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for additional physical therapy services. The Official Disability Guidelines (ODG) recommend physical therapy for patients with scoliosis (curvature of the spine) for 12 visits. ODG supports active therapy and not extensive use of passive modalities. ODG further states that the most effective strategy may be delivering individually designed exercise programs in a supervised format (for example, home exercises with regular therapist follow-up), encouraging adherence to achieve high dosage, and stretching and muscle-strengthening exercises seem to be the most effective types of exercises for treating chronic low back pain. Peer-reviewed literature also supports exercise and bracing for non-operative treatment of adult idiopathic scoliosis. Here, the patient presents with back pain due to his underlying scoliosis. He has completed 12 recent visits of physical therapy with elimination of pain and resumption of full activity. The patient reportedly met all physical therapy goals and had been instructed in an independent home exercise program. There is no rationale presented to support the medical necessity of additional physical therapy at this time. There is no current documentation of a specific functional deficit or functional treatment goal to be addressed by additional supervised physical therapy over continuation of his independent home exercise program. Therefore, the request for additional physical therapy services are not medical necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services 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 orthopedic 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 authorization and coverage for Freestyle Libre continuous glucose monitor (CGM).A CGM system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Over the last decade, CGM systems have been demonstrated to be clinically valuable. A CGM system can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose in clinical and public diabetes management settings, and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Henquin states that a CGM system has been confirmed to be a safe modality, with high accuracy in glycemic values and a low complication rate. Thus, the requested Freestyle Libre CGM is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and metabolism 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 patient has requested authorization and coverage for an oral mandibular device. Findings:  The physician reviewer found that oral appliances that reduce upper airway collapse by advancing the mandible are generally well tolerated and an alternative to continuous positive airway pressure (CPAP) therapy. In this case, the patient has sleep disordered breathing, likely resulting from upper airway resistance, and an Epworth score of 10. Given that the provider has recommended an oral mandibular device and that these devices work to open the posterior airway space, the requested device is medically indicated. Therefore, an oral mandibular device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 oral and maxillofacial 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

A male enrollee requested Viekira Pak and ribavirin for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Successful hepatitis C treatment results in sustained virologic response and is expected to benefit nearly all chronically infected persons.  All told, the requested Viekira Pak and ribavirin are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested surgical implantation of a bone-anchored hearing aid (BAHA) for treatment of her hearing loss. Findings:  The physician reviewer found that The BAHA is indicated for use in patients with hearing loss who cannot tolerate the use of a conventional amplification device. In the past, this was often interpreted to mean patients with external or middle ear disease that precluded the use of traditional hearing aids. Over the years, the use of this device has been expanded to include patients with severe unilateral sensorineural hearing loss. It has been found that there is a reduction in head-shadow effect and enhancement of speech recognition with the use of a device that routes sounds from a hearing impaired ear to a contralateral normal or lesser impaired ear. Both the BAHA and the contralateral-routing of signal (CROS) hearing aid accomplish this. While there have been some recent study results which indicate that patients prefer the BAHA over the CROS hearing aid, objective data in this regard is not yet conclusive. This patient has not had a trial of CROS amplification. A three to six-month trial of the CROS hearing aid is a reasonable next step, rather than an immediate jump to surgical intervention and its related risks. If the patient continues to function poorly in her work situation, thus failing the trial, then authorization for BAHA placement should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male has requested occupational therapy and speech therapy for treatment of his autism.  Findings:  The physician reviewer found that this patient has been receiving occupational therapy and the patients parent has requested that this therapy continue. The patients parent has also requested that this patient receive speech therapy to treat his autistic disorder. Occupational therapy and speech therapy are standard treatment modalities for children with autism. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. Based on an overall evaluation of the literature regarding children with autism, I find the requested occupational and speech therapies to be medically necessary in the treatment of this five-year-old male patient.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female has requested a motorized power wheelchair for treatment of her cardiomyopathy.  Findings:  The physician reviewer found that the records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device. The records indicate that she recently underwent a physical therapy evaluation that noted that she would be safe for ambulation in the home with a walker and that a power wheelchair would only be used for community mobility. In addition, the evaluation noted that the patient was having difficulty using a manual wheelchair at home due to carpeting and throw rugs. The patient would be able to use a manual wheelchair in her residence if the carpeting and throw rugs were removed. The patient has multiple chronic health conditions, such as heart disease and vascular disease that would benefit from increased physical activity and exercise. Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments (Hastings, et al; Valent, et al). Overall, a power mobility device is not medically necessary for this patient given that her mobility deficits in the home can be addressed by other means.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 76-year-old female who has a history of multiple eye surgeries. The surgeries performed on the left eye in 1988 and 1989 resulted in right eye exotropia and strabismus. The patient now has 20/200 vision in her right eye and does not experience any double vision. The patient is requesting coverage for strabismus surgery to correct a large angle exotropia in the right eye. The Health Plan has denied this request on the basis the requested surgery is not medically necessary for treatment of the patients condition.The patients exotropia is due in part to prior surgeries, but is primarily the result of a sensory loss of vision in the right eye. The patients condition is characterized as sensory exotropia. Her vision is very poor in the right eye so there is no potential for binocular fusion in this patient. Binocular depth perception is not possible when one eye has such poor vision. Surgical correction of the strabismus would not lead to functional improvement and is thus a cosmetic procedure.  Therefore, I have determined the requested eye surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee has requested Chemoresistance/Chemosensitivity Assay (ChemoFX assay). for evaluation of her infiltrating ductal carcinoma.  Findings:  Three physician reviewers found that use of chemotherapy sensitivity is not considered a standard of care and is not routinely recommended. The National Comprehensive Cancer Network (NCCN) has designated use of this test as category 3, meaning that based on any level of evidence, there is major disagreement regarding whether the intervention is appropriate. The American Society of Clinical Oncology (ASCO) also does not endorse the use of chemotherapy sensitivity testing outside of a clinical trial. The best evidence suggesting utility for ChemoFX is in the context of patients with ovarian carcinoma. However, there is a paucity of good evidence supporting its use in the management of this patient with early breast cancer. Decisions regarding further management of this patient would revolve around whether adjuvant chemotherapy would be of benefit in reducing the risk of recurrence. For that purpose, tools such as Adjuvantonline! and OncotypeDx have been shown to be useful. For these reasons, the diagnostic testing at issue was not likely to have been more beneficial than standard testing in evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested inpatient psychiatric hospitalization services for medical treatment of his major depressive disorder status post pedestrian versus motor vehicle accident.  Findings:  The physician reviewer found that the documentation provided did not substantiate the medical necessity of acute level of care services. The documentation included a medication list and a history and physical, but did not include important elements such as a psychiatric assessment, treatment plan, physician impression and daily progress notes. Overall, there was no report of suicidal ideation, homicidality, psychosis, delusions, paranoia, rumination, anxiety, insomnia or disordered thinking. Further, the extent and outcome of evidence-based therapies and community interventions in less restrictive settings during the episode of illness was not detailed. Thus, there is a lack of evidence to suggest that the absence of acute hospitalization would have resulted in significant morbidity and likelihood for re-admission. Since modern psychiatric practice favors community-based treatment as outcome measures and therapeutic gains are optimized in this environment, inpatient psychiatric hospitalization services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 26-year-old male enrollee has requested authorization and coverage for psychiatric intensive outpatient program (IOP) services for treatment of this patients medical condition Findings:  The physician reviewer found that he did not demonstrate suicidal or homicidal ideation, nor did he attest to self-harm urges or behaviors. There were no emotional, behavioral, or cognitive factors precluding him from stepping down to outpatient level of care. He was medically stable. His mood and affect remained essentially unchanged. He participated in his treatment plan, was attending Alcoholics Anonymous (AA) meetings regularly. There was nothing to indicate that he would deteriorate or decompensate if returned to his environment. He was using sober supports of the sober living environment. Goals were met in that he remained sober, his daily living functioning was stable and at baseline. All told, the requested IOP services are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested neuropsychological testing for evaluation of her medical condition. Findings: The physician reviewer found that the clinical standard in determining the need for neuropsychological testing is to perform in-office cognitive assessments such as the mini mental status exam and/or the MoCA. Scores that are low or borderline low would suggest that more detailed testing should be conducted. In this case, there is a lack of evidence showing that in-office testing has been conducted which would demonstrate the need for a neuropsychological testing. While neuropsychological testing should be done after traumatic head injuries, it is customary to do so within two to six months of the injury. In this case, years have elapsed since the patient suffered a traumatic head injury.   For the reasons provided above, the request for neuropsychological testing is not clinically indicated for this patient.  Final Result:  The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Guardant Health Laboratory Tests. The enrollee has breast carcinoma originally diagnosed as multifocal infiltrating lobular cancer node negative classic type. She had aggressive chemotherapy at that time, went into menopause and then developed a local recurrence in her late 50s.  Lymph nodes were removed, she had radiation therapy to her axilla and she has been on tamoxifen with no evidence of systemic relapse.  Her tumor DNA has been non-detectable after she was started on tamoxifen.  Her routine bloodwork indicated a normal CA 15-3 but the circulating tumor DNA showed a re-appearance of the BRCA mutation shown initially on her first test.  Thus, the DNA test was repeated. The Guardant360 report indicated somatic alterations were detected in the circulating cell-free DNA isolated from the enrollees blood specimen.  The genomic alterations were cancer-associated somatic variants, some of which have been associated with either increased or reduced clinical response to specific treatments. According to the literature, liquid biopsies can be performed when tissue biopsy is inaccessible or unavailable. While the current focus is dominated by DNA, additional components of a liquid biopsy include ribonucleic acids (RNA), circulating tumor cells (CTCs), extracellular vesicles (EVs), and tumor educated platelets (TEPs).  The latter components are mainly of research interest.  As more translational research is performed, these additional components of a liquid biopsy may have increasing clinical use in the future.  Although liquid biopsy may be an attractive tool for cancer screening in asymptomatic enrollees, such applications will need to be carefully and thoughtfully considered to avoid excessive anxiety due to false positive results, and the research in ongoing.  The Guardant360 test or a similar test to detect the circulating cancer cells in this enrollee with breast carcinoma is not recommended in the textbooks or the national guidelines. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in medical oncology. One review is board certified in clinical cytogenetics and clinical genetics. All are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.