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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for anastrozole. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The use of anastrozole is not a widely accepted method to increase height potential of short children. There are safety concerns that have not been adequately addressed. This patient is not the typical short child where studies with anastrozole have been shown to have some benefit. Per the records, it is likely that his short stature is a result of the other medical problems he has had, including nutritional issues and a history of small for gestational age. The use of anastrozole in the setting of nutritional defect has not been proven in clinical studies. This patient has an estimated predicted height of 56 with the current therapy, which is a normal adult height. Anastrozole is an aromatase inhibitor that blocks the conversion of testosterone to estradiol and can delay bone age advancement caused by increasing levels of testosterone in otherwise healthy short boys that progress in puberty physiologically. However, this patient does not have the typical problem of otherwise healthy short boys because he has partial testicular failure and is on treatment with testosterone. Thus, anastrozole is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested radiofrequency ablation for the treatment of her rectal cancer with pulmonary metastases. Findings:  Three physician reviewers found that radiofrequency ablation (RFA) for metastatic pulmonary nodules is an investigational treatment. RFA is currently under clinical investigation for treatment of pulmonary lesions. At this time, there is no peer-reviewed evidence demonstrating that RFA for the treatment of pulmonary lesions is superior to standard therapies. Nor is there adequate data to determine the safety of the proposed RFA in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for use of Mako robotic system (CPT 27447) for a right knee arthroplasty procedure. While it is recognized that radiographic parameters can be optimized compared to conventional instrumentation, there is a lack of data in current medical literature showing that midterm outcomes from such procedures are superior to standard instrumentation. In a network meta-analysis, Bouche and colleagues recommend against the use of navigation and other new approaches due to the risks associated with the uncertainties of novel surgical approaches. Shatrov and Parker report that while early clinical outcomes show promising results for computer-assisted total knee arthroplasty, longer-term data is still to come. Therefore, use of Mako robotic system (CPT 27447) for the patients right knee arthroplasty procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapyFindings:  Three of the three physician reviewers found the requested use of Mako robotic system (CPT 27447) for a right knee arthroplasty procedure 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 service is 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for infusions of intravenous (IV) iron sucrose (Venofer 100 mg/5 mL inj) every six months to one year. The records provided for review document that this patients ferritin level was elevated as expected following iron infusions, and these levels have fallen over time. However, the patients most recent level was 70 ng/mL with a normal hemoglobin and hematocrit. Ferritin is an acute phase reactant and numbers can fluctuate for a variety of reasons. The typical cut-off for a low level of ferritin is below 30 ng/mL. The patients laboratory results are not diagnostic of iron deficiency as ferritin levels do not indicate hypoferritinemia at a level of 70 ng/mL. Moreover, the patients symptoms of fatigue, hair loss, and feeling cold are not specific to iron deficiency. All told, the requested infusions of IV iron sucrose (Venofer 100 mg/5 mL inj) every six months to one year are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for full body magnetic resonance imaging (MRI). Findings:  The physician reviewer found that The arthritis and arthralgias of systemic lupus erythematosus (SLE) are typically nonerosive and generally different from that of rheumatoid arthritis (RA), tending to be migratory, with symptoms in a particular joint that may be gone within 24 hours or last longer. While the arthritis may involve any joint, it is usually symmetric and polyarticular, with a predilection for the knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint. The ankles, elbows, shoulders, and hips are less frequently involved, and involvement of the sacroiliac joints and cervical spine is rare. While an ultrasound or MRI may reveal chronic synovitis, this would not change the management approach for SLE, nor would it reveal any potential undiagnosed fibromyalgia which may also be contributing to pain in this patient.  Additionally, in this case, as the records note that the patients diagnoses include SLE and class 5 nephritis, any MRI, with contrast, is not indicated due to the risk for contrast nephropathy. Rather, the patients generalized functional pain should be evaluated clinically, and concerns regarding specific organ involvement should be addressed separately and specifically. Given that MRI is not the preferred modality to diagnose and treat generalized polyarthralgia, the requested service is not medically indicated. Therefore, the requested full body MRI is not medically necessary for the evaluation of 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 reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for carotid duplex scan. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  The records noted increased cardiovascular risk.  The report also noted a history of dizziness.  There is no documentation to support known carotid stenosis, focal neurologic symptoms, focal neurologic abnormalities on physical examination, carotid bruits or other standard accepted indications to perform a carotid ultrasound.  Screening carotid ultrasounds in this clinical setting are not supported by current guidelines.  In addition, a carotid ultrasound to evaluate for nonspecific dizziness without documented focality or other concern for carotid stenosis is not considered standard accepted practice in the medical community.  Therefore, carotid duplex scan was not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year, eight-month-old female enrollee has requested authorization and coverage for speech therapy, at half hour sessions, twice per week. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech delay.   Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Similarly, Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition at the requested frequency of twice per week.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a panniculectomy/abdominoplasty for treatment of her recurrent incisional hernias.  Findings:  The physician reviewer found that the patients MRI studies do not show any hernias. She has fascial laxity without a true hernia. The abdominal wall procedures will improve contour but will not treat a true hernia. Panniculectomy/abdominoplasty to facilitate hernia repair is not necessary because the patient does not have a true hernia.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old male enrollee has requested Novo-TTF-100 (electric tumor treatment field) for treatment of his  recurrent glioblastoma. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be more effective than other treatment alternatives.  The medical evidence supports the requested services in this clinical setting.  Turner and colleagues noted that combining chemotherapy with Novo-TTF therapy may improve efficacy without added toxicity.  This patient has undergone recurrent craniotomy and maximal radiation, as well as chemotherapy. All other chemotherapy options are likely to carry greater hazard, and no evidence of better outcome, than the requested services.  Therefore, Novo-TTF-100 (electric tumor treatment field) is likely to be more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested repair of ruptured left breast saline implant for treatment of her left breast pain.  Findings:  The physician reviewer found that based on the documentation provided, the original surgery was aesthetic/cosmetic in nature. There was no documentation to suggest a history of congenital deformity, neoplasm or other condition to necessitate medically necessary breast reconstruction. Implant rupture is a well-recognized complication related to augmentation mammaplasty (Jones). The American Society of Plastic Surgeons (ASPS) define cosmetic surgery as surgery that is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem, and reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Reconstructive surgery is generally performed to improve function, but may also be done to approximate a normal appearance. Thus, this patients original surgery is consistent with cosmetic surgery and the patient is experiencing a well-recognized complication related to her cosmetic surgery. Further, the patients complaints are not consistent with the level of documentation provided in the medical record. The patient states that she has severe pain that significantly limits her activity. However, the documentation provided by the provider does not include evidence of these complaints and the examination does not include findings of tenderness with palpation or other reasons for having severe pain. In addition, attempts at conservative pain control are lacking. Overall, the records fail to establish the medical necessity of the requested repair of ruptured left breast saline implant for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The representative (spouse) of a 49-year-old male enrollee has requested for brain injury rehabilitative/coma stimulation for treatment of the enrollees anoxic encephalopathy.   Findings:  Two physician reviewers found that the patient has been receiving all three available therapies (occupational, speech, and physical). Progress is documented, but it has been very slow. There is no evidence submitted or in the literature that would support coma stimulation as yielding better outcomes that standard therapies. Continuation of this patients current therapies (OT, ST, and PT) are indicated if the patient continues to progress, but coma stimulation is not indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested continued speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patients speech is delayed at the 24-month level and speech therapy services are indicated. However, the patient also needs to undergo a complete speech and language evaluation. Speech therapy is recommended for patients with delays greater than 25% (Volmar and Weisner). Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty.  Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested an MRI of the right breast for an evaluation due to her history of papillary thyroid cancer.  Findings:  Two physician reviewers found that this patient has an established diagnosis of thyroid cancer.  In her initial post treatment scan, there was a question of a metastasis in the right breast.  This requires further evaluation, as a metastatic lesion would require additional treatment.  However, the requested MRI is not the most efficacious method of evaluating this patient at this time.  In this clinical scenario, mammogram and ultrasound are indicated. MRI of the breast is not a first-line modality of choice in the evaluation of a breast lesion. MRI may be a useful complementary study when mammography and ultrasound fail to fully evaluate a finding.  In this patients case, the requested MRI of the right breast is not likely to be superior over other available methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for budesonide for treatment of the enrollees chronic ulcerative colitis and Barretts esophagus. Findings:  The physician reviewer found that the use of oral budesonide for active ulcerative colitis is not supported due to a lack of effectiveness. Budesonide was not more beneficial than placebo. There is no evidence to recommend the clinical use of oral budesonide for the induction of remission in active ulcerative colitis. A budesonide multi-matrix (MMX) formulation is available as 9 mg extended release and has been demonstrated to be more effective than placebo for ulcerative colitis. However, there is a lack of data supporting the requested budesonide 3 mg three times daily as medically necessary for the treatment of this patients ulcerative colitis. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-month-old male enrollee has requested palivizumab (Synagis) injections for treatment of the enrollee, who was born at 32 weeks gestation. Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from respiratory syncytial virus (RSV) in infants born at 32 to 35 weeks gestation. The most striking of these is a birth weight less than 2500 grams.  An infant with a birth weight between 1500 and 2500 grams is five times more likely to die from RSV infection than an infant with a birth weight greater than 2500 grams.  Simoes and colleagues have developed a model based on seven risk factors to predict which infants born between 32 and 35 weeks are at highest risk of severe RSV disease. This patients risk factors include gestational age and birth weight less than 2500 grams, placing him at risk for significant morbidity from RSV disease.  The Impact-RSV Study Group examined the effect of palivizumab prophylaxis on severity of illness in premature infants.  The study demonstrated a significant decrease in hospitalization rate for all infants. For infants born between 32 and 35 weeks gestation that received palivizumab prophylaxis, there was an 80% decrease in hospitalization rate. Palivizumab prophylaxis has shown continued efficacy in reducing severity of illness.  All told, palivizumab (Synagis) injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for applied behavior analysis (ABA) therapy for 40 hours per week from the date of service in question, forward.  Findings:  The physician reviewer found that the submitted records support the medical necessity of the services at issue in this clinical setting.  The correlation between treatment outcomes and treatment intensity is well documented.  In a recent article on the efficacy of ABA , the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress.  In this case, the patient appears to have made progress in many areas as over the last several years, but continues to demonstrate impairment in vocal stereotypy, self-stimulation and self-injury.  These persistent struggles are making it difficult for the patient to be successful in more generalized environments. The patient has been authorized for approximately 18 hours per week of direct ABA therapy, which is less than what is typically recommended for optimal response.  The medical evidence supports the services at issue in this clinical setting.  All told, ABA therapy for 40 hours per week from the date of service, forward was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.