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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for stereotactic body radiotherapy for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that The physician reviewer found the medical evidence has not established the superior effectiveness of stereotactic body radiotherapy in this clinical setting. Outcome data for stereotactic body radiotherapy at this time is limited to five-year to six-year follow-up. The study by Katz and colleagues evaluated prostate cancer patients treated with stereotactic body radiotherapy (total patient number was 304, and 81 were intermediate-risk). The five-year biochemical disease free survival was 90.7% for intermediate-risk, and toxicity was also acceptable.  Overall, these outcome data appear similar to conventionally fractionated radiotherapy, but do not demonstrate that stereotactic body radiotherapy is likely to be more beneficial. Additionally, longer follow-up would be optimal due to the long natural history of prostate cancer.  In sum, stereotactic body radiotherapy was not likely to have been of greater benefit than conventionally fractionated intensity modulated radiation therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in radiation oncology 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.Physician reviewer number two is board certified in radiation oncology 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.Physician reviewer number three is board certified in radiation oncology 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

The patients parent has requested reimbursement for mental health services. Treatment in a group home or RTC facility would have been appropriate in this clinical setting. However, the patient participated in a wilderness therapy program that is accredited as an educational program, but not as an RTC. CALOCUS specifies the essential elements a program needs to provide adequate care at the RTC level. An RTC involves treatment in which the essential element is the maintenance of a milieu in which the therapeutic needs of the child or adolescent and family can be addressed intensively. Researchers reported that patients should be treated in the safest and least restrictive environment and needed services should be wrapped around to provide more intensive home or community-based services. When less restrictive resources are inadequate or inappropriate for the patients needs, an RTC may be indicated. The researchers noted that the mental health services should include a psychiatrist with training and experience consistent with the age and problems of the children and should be family-driven. The records do not demonstrate that the appropriate level of care was provided. Specifically, there is no mention of a psychiatrist or primary care provider being involved in the patients treatment. Further, the services provided were not family-driven. All told, the mental health services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder and anxiety. Findings:  Three physician reviewers found that although relatively new, TMS is effective treatment as demonstrated in the peer reviewed medical literature. In addition, TMS is becoming more widely used, has been granted a category I CPT code by the American Medical Association and is FDA approved for the treatment of treatment-resistant major depressive disorder. For these reasons, the requested TMS therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy and should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Overturned

A 72-year-old male enrollee has requested a PET/CT scan for an evaluation of hiss cholangiocarcinoma. Findings:  Two physician reviewers found that the patient has been treated with radiation and chemotherapy.  His referring physician requests a PET/CT scan for restaging.  Renal insufficiency precludes intravenous contrast administration for MRI or CT scanning, thus limiting the usefulness of each modality for the detection of recurrent or metastatic tumor. The Health Plan does not include cholangiocarcinoma as a covered indication for PET/CT scans. The Health Plan has denied coverage for the PET/CT scan. Of note in this case is the unusual situation in which the patients elevated serum creatinine precludes intravenous contrast administration for MRI and CT scans, which in turn compromises each modality in the search for a soft tissue tumor. The PET Oncology Registry has recommended PET scanning in the staging of all tumors and is awaiting a ruling from CMS on this recommendation sometime in 2008.  PET/CT could be of use, particularly in light of the contraindication to IV contrast. The diagnostic procedure is likely to be more efficacious for evaluation of this patients condition than alternate diagnostic methods.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a four-year-old male enrollee has requested for sensory integration therapy for treatment of the enrollees reported diagnosis of a sensory integration disorder. Findings:  Two physician reviewers found that there is sufficient medical evidence of the efficacy of sensory integration occupational therapy in children who demonstrate deficiencies in formal testing and sensory integration therapy has a robust medical literature as to its long-term value.  Schaaf and Miller utilized sensory integration techniques that enabled the occupational therapist to assist a developmentally delayed child to develop the ability to integrate into normal motor and personal-social patterns to function with his peers.  Miller and colleagues reported significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children in a well-controlled study. Additionally, Roberts, et al. described improvements of behavior patterns in children who have been treated with occupational therapy, utilizing sensory integration techniques. All told, occupational therapy utilizing sensory integration therapy is medically appropriate for the treatment of this patient, following a comprehensive occupational therapy evaluation to determine his specific needs.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne test. Findings:  Three physician reviewers found that although tumor based molecular assays are recommended by the National Comprehensive Cancer Network (NCCN) guidelines for men with clinically localized disease, generalized molecular testing, such as with FoundationOne, is not supported by the NCCN Guidelines for prostate cancer. The use of molecular profiling for prostate cancer and other solid tumors is the subject of an ongoing clinical trial. There is also some data suggesting that intratumoral heterogeneity limits the use of gene expression analysis as a potential prognostic or predictive biomarker in patients treated with androgen deprivation therapy. Therefore, FoundationOne test was not likely to have been more effective 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 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested for neuroelectrode implants (percutaneous tibial nerve stimulation) for treatment of her overactive bladder condition.   Findings:  Three physician reviewers found that the FDA has approved a device for PTNS (called URGENT PC) for patients with intractable overactive bladder symptoms of urgency, frequency and urge incontinence. The cited references (see above) review this technology, but long-term and/or placebo controlled studies are lacking and therefore PTNS remains an unproven therapy for the patients condition at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female has requested coverage for Roux-en-Y gastric bypass with biliopancreatic diversion with duodenal switch (BPD/DS) for treatment of her obesity status post gastric bypass in 2005.  Findings:  The physician reviewer found that based on review of the available records, this patient is status post gastric bypass in 2005 and currently is morbidly obese. The records indicate that the procedure worked well for the patient with loss of over 170 pounds then regained the weight. On EGD, there was no obvious anatomical failure of the patients previous gastric bypass. The patients chart documents very little surgical follow-up since her prior procedure and no dietary or behavioral follow-up. To be considered for the requested revisional procedure, it is clinically reasonable to ensure the patient is likely to comply with the dietary and surgical follow-up required. Further, revisional surgery is associated with an increased risk of leak and complications, including protein malnutrition, which need to be reviewed with the patient. The records indicate the patient was able to lose weight with the procedure and yet weight regain occurred. For these reasons, the patient may be a candidate for revisional surgery in the future however without documentation of a thorough multidisciplinary evaluation, the requested revisional surgery is not medically necessary for management of her condition at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual acupuncture treatments, twice per week for five weeks followed by weekly individual acupuncture treatment for up to sixteen weeks. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: The medical literature supports that acupuncture has been found to be effective when compared to no treatment for short term pain relief in chronic low back pain, chronic headaches and neck pain. Additionally, there is some evidence that acupuncture has been shown to provide and add benefit alongside conventional therapy. However, in this clinical setting, the documentation provided does not support the medical necessity of the requested services. In this case, the records indicate that this patient has already completed sessions without any extraordinary circumstances noted. The records do not report objective or specific gains obtained with the acupuncture treatment provided. The patient is requesting additional acupuncture sessions. There is a lack of evidence in peer reviewed literature for the efficacy of long term acupuncture therapy especially in the absence of measurable objective gains. Consequently, individual acupuncture treatments, twice per week for five weeks followed by weekly individual acupuncture treatment for up to sixteen weeks is not supported as medically necessary for treatment of her 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 oriental 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 anterior lumbar interbody fusion surgery for treatment of the enrollees chronic low back pain.  Findings: The physician reviewer found that the medical records do not show any evidence of lumbar instability, fracture, or tumor. Also, there are no flexion-extension x-rays showing more than 5 mm of abnormal motion at any lumbar segment. Lumbar fusion for degenerative disc condition is not more effective than conservative measures for low back pain treatment. This patients records do not demonstrate that conservative treatment has been exhausted. All told, the requested anterior lumbar interbody fusion surgery is not medically necessary for treatment of this patients low back pain.Final Result: The reviewer determined that the requested surgery 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 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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that it is difficult to differentiate autism and attention deficit hyperactivity disorder (ADHD). Many children with ADHD will have some difficulties with social interactions due to not paying attention and missing social cues. The in-Plan developmental-behavioral pediatrician separates these two symptoms and notes the impact of the language delays on all of his behaviors. The patient had a positive autism diagnostic observation schedule (ADOS) but that report did not take into account the significant impact of ADHD on eye contact and social awareness nor the impact of his language processing difficulties. In addition, there is some evidence in the medical literature that the ADOS is an imperfect evaluation tool (Zander, et al). The article by Zander and colleagues shows that the ADOS scores across settings were not always consistent and especially when there were co-occurring problems such as ADHD or language based problems. Given the entirety of the clinical documentation submitted, the most recent evaluation by the in-Plan developmental-behavioral pediatrician adequately fits the patients diagnosis of ADHD with no clinical signs of autism. As such, ABA therapy is not clinically indicated for this patient.  Final Result: Two reviewers 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: One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatric and is actively practicing. One reviewer is board certified in child neurology and is 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 37-year-old male enrollee has requested reimbursement for the partial hospitalization program (PHP) services. The records provided for review document that the patient showed no withdrawal or post-acute withdrawal symptoms. He was not a danger to himself or others, nor was he aggressive or violent. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant PHP level of care. He was medically and psychiatrically stable. He was not psychotic or manic. He showed no signs of impulsivity or agitation. His medication management and Suboxone induction could have been performed in an ambulatory setting, which is where is it is commonly performed. He lived in a supportive environment. For these reasons, the patient could have been safely and adequately treated at the intensive outpatient program (IOP) level of care. Thus, the PHP services provided were not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned

A 76-year-old male enrollee has requested a positron emission tomography (PET/CT) scan for evaluation of the enrollees renal cell carcinoma.  Findings:  Two physician reviewers found that the records indicate the patient has been found to have widespread metastatic disease. Prior positron emission tomography/computed tomography (PET/CT) scans have shown the tumors to be PET avid. After different therapeutic trials, the provider has recommended a repeat PET/CT to evaluate the patients treatment success. The patients request for authorization for the PET/CT was denied by the Health Plan as they consider the requested diagnostic procedure to be investigational and experimental for evaluation of the patients response to treatment. The patient does not carry a diagnosis of the usual kidney cancer where PET has been shown to be of very limited value. Rather the patients diagnosis is transitional cell carcinoma of uroepithelium, which is a tumor type where PET has been proven in the medical literature to be useful (Patil, et al). As in this patients case, where the metastatic tumors have been PET avid in the past, findings on further PET/CT is being done to evaluate response to treatment (Jadvar, et al). Since the PET/CT is especially helpful in patients with this diagnosis and has proven beneficial in this patients evaluation and treatment in the past, the diagnostic procedure is likely to provide useful information relevant to this patients care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for myofascial release treatment. A randomized controlled clinical trial published by Ceca and colleagues evaluated the benefits of myofascial release techniques on patients with fibromyalgia. The authors found statistically significant improvements in pain intensity, fatigue, stiffness, depression, and range of motion. Researchers assessed the effectiveness of different styles of massage therapy in fibromyalgia. The authors concluded that myofascial release demonstrated positive effects on pain and medium effects on anxiety and depression at the end of treatment, in contrast with placebo; effects on pain and depression were maintained in the medium and short-term, respectively. In this case, the patient has chronic pain with central sensitization involving multiple areas in both the upper and lower extremities, specifically, in the legs, knees, and hands. The patients presentation is consistent with fibromyalgia, which is a form of central sensitization to chronic pain. Given the support in the peer-reviewed medical literature, there is evidence to support benefit of myofascial release for patients with fibromyalgia and chronic myofascial pain syndromes. These studies have demonstrated that this therapy can positively improve quality of life measures for patients living with fibromyalgia and myofascial pain syndrome. For these reasons, the requested myofascial release treatment is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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.