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

A 56-year-old female enrollee has requested an arthroscopic procedure for the treatment of her left hip pain. Findings:  Two physician reviewers found that trochanteric bursitis represents a very common condition. Most patients with this condition respond to non-operative management including physical therapy modalities, anti-inflammatory medications, activity-level changes, and in many instances, steroid injections. When non-operative management does fail for a prolonged period of time, surgery can be undertaken. This patients case indeed represents a rare instance since in most cases non-operative management is most successful. Arthroscopic surgery in the treatment of recalcitrant bursitis has had growing support in the literature. A study by Fox reports that 80% of the patients studied had good to excellent results. Baker and colleagues concluded that arthroscopic surgery is effective as an option for recalcitrant trochanteric bursitis. Larson and colleagues report that although early outcomes of all-arthroscopic treatment are only beginning to be reported, they appear to compare favorably with those of open procedures. The arthroscopic surgery used in this patients case was appropriate and effective in the treatment of her recalcitrant pain resulting from chronic bursitis and other tissue damage. Given that the patient was no longer responding to conservative measures, the disputed surgery was a reasonable approach in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for no more than three hours per month of direct supervision in the home of applied behavior analysis (ABA) therapy by a supervising board certified behavior analyst (BCBA) for 12 months (direct supervision in the home of ABA therapy by a supervising BCBA may be increased by one hour every two months, or as deemed necessary by the BCBA, based upon the enrollees response to direct supervision) utilizing the skills acquisition goals and timeline outlined in the Centers Treatment Plan. Based on the presenting information, the Behavior Analyst Certification Board (BACB) standards of practice and the medical necessity definition do not support the requested supervision hours. The BACB developed practice guidelines as well as subsequent clarification guidelines. These guidelines posit that the appropriate amount of supervision is two hours for every 10 hours of therapy. Further, the guidelines specify the BCBA should set the dosage of supervision. In this case, the provider recommended eight hours of supervision per month to meet the patients healthcare needs. The case also fails to meet the medically necessity definition. As the BCBA requested eight hours of supervision per month, the three hours of supervision per month are not enough to meet the essential needs of the patient. In addition, three hours of supervision per month are not consistent the scientifically based guidelines as determined by medical research. Finally, the request for three hours per month is based on convenience for the family. All told, no more than three hours per month of direct supervision in the home of ABA therapy by a supervising BCBA for 12 months (direct supervision in the home of ABA therapy by a supervising BCBA may be increased by one hour every two months, or as deemed necessary by the BCBA, based upon the patients response to direct supervision) utilizing the skills acquisition goals and timeline outlined in the Centers Treatment Plan, is not medically necessary for treatment of this patient.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 a licensed B.C.B.A board certified in psychology 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: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) injections for bilateral knees. There is limited reliable clinical evidence to guide the use of PRP. Although no major or permanent complications have been reported in short-term clinical trials, there is a paucity of prospective randomized controlled clinical trials demonstrating improved patient health outcomes with PRP over standard therapies. Researchers found that the effects of PRP on knee osteoarthritis are mixed and the research is limited. Researchers concluded that PRP should not be preferred to hyaluronic acid. Authors concluded that leukocyte-poor PRP resulted in improved functional outcomes as compared to leukocyte-rich PRP, hyaluronic acid, and placebo injections. Given these findings, the requested PRP injections for the bilateral knees are not 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 PRP injections for the bilateral knees are 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 services are 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test for treatment of the enrollee's uterine leiomyosarcoma. Findings: Three physician reviewers found that currently, therapy and achieved outcomes for metastatic uterine leiomyosarcoma are not based on panel testing. To demonstrate the clinical utility of panel genetic testing, such as FoundationOne, prospective randomized clinical trials are needed to compare the strategy of targeted treatment based on panel results with standard of care and currently there is a lack of such trials. The available literature as to its clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. As such, this evidence is not sufficient to make any conclusions as to its efficacy in this clinical setting. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. Accordingly, the use of expanded mutation panel testing for targeted treatment in cancer is considered investigational and should only be conducted in the setting of a clinical trial. Therefore, the FoundationOne gene test performed was not likely to have been more effective than the available options for the evaluation of this patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers 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

The parent of a three-year-old male enrollee has requested speech therapy services for the treatment of the enrollees condition. Findings:  The physician reviewer found that during the period at issue the patient presented with significant speech and language delay that adversely impacted communication with those around him. These difficulties prevent him from acquiring the usual skills of childhood. In addition to expressive language delay, he exhibits oral motor dysfunction, dysarthria, a motor planning disorder, and feeding difficulties. Speech therapy is imperative to treating these issues successfully. As the article by Nelson and colleagues indicates, Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. 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  preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. They may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. This may lead to overall academic underachievement and, in some cases, lower IQ scores that may persist into young adulthood. In addition to persistent speech and language-related underachievement (verbal, reading, spelling), language-delayed children have also shown more behavior problems and impaired psychosocial adjustment. In summary, this patient has significant delays in multiple areas, and has shown consistent improvement over time, as demonstrated during multiple assessments. He required continued speech and language therapy to maximize his skills in communication, oral motor function, and feeding. Speech therapy was therefore medically necessary and appropriate in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stab phlebectomy treatment of the enrollees varicose veins. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The treating provider did not provide sufficient information to justify the proposed treatment. This patient has deep and superficial reflux bilaterally. There are cases where phlebectomy alone may be appropriate, even with reflux present. However, the reasoning for such a decision is not supplied in this case. The medical evidence does not support the requested services in this clinical setting. 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 vascular 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Tazorac cream.Findings:  Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting. The treatment of palmoplantar psoriasis can involve targeted therapy with topical steroids and topical keratolytic medications. This patient has tried and failed therapy with clobetasol and urea 40% cream, as well as ammonium lactate 12%. She has failed therapy with intralesional steroids. The use of topical retinoid creams as a keratolytic agent is commonly used in dermatology to reduce hyperkeratosis and increase penetration of topical steroids. The requested medication is appropriate in this clinical setting. Therefore, Tazorac cream is likely to be superior over other treatment options. Final 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 reviewers 1, 2 and 3 are board certified in dermatology 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

The parent of a four-year-old male enrollee has requested speech and occupational therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that both speech therapy and occupational therapy are medically indicated for treatment of this patient. Plasticity in the developing brain can be utilized to improve overall neurologic health. Specific treatment, including speech therapy and occupational therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic process. Based upon this patients diagnosis and current deficits, he is an appropriate candidate for the requested therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing performed for evaluation of the enrollees hepatitis B. Findings: Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The patient needed the test called the FibroTest, which is an accurate noninvasive panel of blood tests that include alanine aminotransferase, alpha-2-macroglobulin, apolipoprotein A1, total bilirubin, gamma glutamyl transferase, and haptoglobin. Based on the values of these six tests, one can accurately estimate the degree of liver inflammation and fibrosis in a patient with hepatitis B or C. This test was not performed to assess cardiac risk but was performed in order to guide the course of treatment for this patients hepatitis B infection. The provider was deciding whether treatment was indicated. Of these six tests, apolipoprotein A1 testing is an advanced lipoprotein test. However, it is a key part of the panel and needs to be done in conjunction with the five other tests. For these reasons, the advanced lipoprotein testing performed was likely to have been more beneficial than the other standard methods for the evaluation of 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 18-year-old male enrollee has requested inpatient psychiatric services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patients psychiatric hospitalization was not medically necessary and services could have been provided at a lower level of care such as a partial hospital program. The records show that the patient did not manifest symptoms consistent with the admission criteria of a nationally accepted protocol (i.e., Milliman Guidelines) for determining medical necessity for inpatient treatment. As compared to these guidelines:a.the patient was not imminently at risk of danger to self or others (he was without plan or intent); b.his behaviors of punching the computer and head banging were solitary (he was reportedly doing well prior to this event);c.he was not intent on harming anyone else d.he did not have any delusions or hallucinations associated with harm to self or others; e.he had no major medical co-morbidities requiring 24-hour nursing care; f.he did not demonstrate any life-threatening inability to perform self care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Oncotype Dx colon cancer assay test. The provider recommended Oncotype Dx colon cancer assay testing to help determine if the patient should receive s deferential amount of cycles of FOLFOX chemotherapy for treatment of stage II colon cancer. Recent literature and guidelines were reviewed, at this time; there is no conclusive evidence supporting the utility of Oncotype DX in treatment determination (predictive markers) or prognosis in patients with colon cancer. The use of OncotypeDx for determining duration of therapy is not an established standard of care. It is not likely to be more beneficial for this patient than any other standard treatment.Final Result: The reviewer determined that the services in 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 internal medicine with subspecialty certification in hematology and medical 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Eliquis. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees deep vein thrombosis.Findings:  The documentation supports the medical necessity of the treatment in question. The patient has documentation of left lower extremity DVT. The medication Eliquis is an approved medication for the treatment of DVT. The records indicate the patient has developed an intolerance to the medication Coumadin with reported bruising and nose bleeds. Therefore, the requested medication Eliquis has been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has 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 vascular 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 63-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his medical condition status post total knee replacement.  Findings:  The physician reviewer found that based on the medical records provided for review, the use of the CPM machine was not medically necessary for treatment of this patients medical condition following total knee replacement surgery. The use of CPM has not been supported after total knee replacement. Chen and colleagues conducted a prospective controlled study on 107 patients. The patients were evaluated for range of motion and visual analog scale assessment at six months postoperatively. The authors concluded that aggressive CPM does not provide obvious benefits. Trezciak and colleagues evaluated 93 patients assigned to two groups. The experimental group was given CPM and active exercise. The control was given conventional physical therapy only. The patients were then followed for range of motion and functional recovery. The findings of this study showed that CPM had no significant advantage in terms of improving clinical measurements. The authors found a beneficial effect on subjective assessment of pain level, joint stiffness and functional ability. All told, the use of CPM for treatment following total knee replacement surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested for use of a real-time heart monitor for evaluation of her syncope and heart arrhythmia.  Findings:  Three physician reviewers found that there is no documentation to indicate this patient was not able to effectively manage standard non real-time event recorders or that these were previously obtained to evaluate the patients symptoms. The current expert consensus guidelines endorsed by several national organizations also consider serial Holter monitoring and patient activated event recorders appropriate tests for evaluation of potential dysrhythmias. Overall, continuous real-time monitoring was not clinically indicated in this case, since analysis of an event recorder would have been sufficient to identify this patients symptomatic dysrhythmias without jeopardizing her safety. Overall, the medical literature has not demonstrated improved health outcomes with use of real-time heart monitoring when compared to standard techniques.