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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a coronary angiogram procedure. This patient had known coronary artery disease and had a previously placed coronary stent. He had been free of symptoms until recently when he developed recurrent anginal type chest pain similar to the symptoms he experienced before his prior stent. He was on beta blocker therapy, and his systolic blood pressure was 108, making further medical therapy for angina problematic and not likely to be well-tolerated. Although he did not undergo stress testing prior to the angiogram, he had known established coronary artery disease, multiple coronary risk factors for progression of his disease and new onset typical and escalating symptoms of angina. Based on the American College of Cardiology criteria, even with a low risk stress test, in a symptomatic patient with known coronary artery disease and prior percutaneous coronary intervention, coronary angiography is medically reasonable. Escalating symptoms suggest an instability to the angina. Therefore, coronary angiogram procedure was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation 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 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 ten-year-old female enrollee has requested for speech and language therapy and occupational therapy for treatment of the enrollees autistic disorder. Findings:  Two physician reviewers found that the idea behind these therapeutic interventions 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 and function through focused treatment. Thus, specific treatment, including speech and language 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 pathogenetic process. This multimodal approach will allow the patient to derive therapeutic benefit.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Trelegy Ellipta inhaler. Researchers note that treatment with an inhaled glucocorticoid, a long-acting muscarinic antagonist (LAMA), and a long-acting 2-agonist (LABA) have been studied as the cornerstone of effective, evidence-based management of chronic obstructive pulmonary disease (COPD). The authors found that triple therapy at two glucocorticoid doses resulted in a lower rate of moderate or severe COPD exacerbations than glycopyrrolate-formoterol or budesonide-formoterol. Given that the patient has responded well to Trelegy in the past, the requested medication is medically indicated. Therefore, a Trelegy Ellipta inhaler is medically necessary for the treatment of this patient. Final Result: The reviewer 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 internal medicine with sub-specialty certification in pulmonary 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for COVID-19 antibody testing. The Centers for Disease Control does not currently recommend antibody testing as the sole basis for diagnosis of acute infection. In certain situations, serologic assays may be used to support clinical assessment of persons who present late in their illnesses when used in conjunction with viral detection testing. In this case, the records do not establish that the patient was exposed to someone with symptoms or evidence of COVID-19. The nature of her illness in December 2019 is unknown. In this clinical setting, the testing is not medically indicated. Moreover, antibody tests for SARS-CoV-2 infections are not well-developed and are often falsely positive. Antibody testing is not standardized, and the results will vary depending on the test that is chosen. Therefore, COVID-19 antibody testing is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 infectious 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage Hyalgan 20 mg/2 mL syringe, once weekly for three weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients osteoarthritis. The submitted documentation supports the medical necessity of the requested medication regimen. A study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with chronic right knee pain and functional limitations in activities of daily living. The clinical examination findings are consistent with x-ray evidence of severe osteoarthritis with bone-on-bone findings in the medial compartment. The record indicates that reasonable conservative treatment, including medications, nonsteroidal anti-inflammatory drug therapy, and corticosteroid injections have failed to provide adequate symptom relief. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Hyalgan 20 mg/2 mL syringe, once weekly for three weeks is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Optune device and transducer array supplies for six month rental/six total units for treatment of the enrollees glioblastoma multiforme. Findings: The physician reviewer found that in the medical literature, treatment with Optune tumor-treating fields (TTFields) in combination with maintenance Temodar prolonged progression free survival and overall survival in patients with glioblastoma after chemoradiation. The study concluded that of 315 patients with glioblastoma who had completed standard chemoradiation therapy, adding TTFields to maintenance temozolomide chemotherapy significantly prolonged progression-free and overall survival. Per the National Comprehensive Cancer Network (NCCN) guidelines, Optune with Temodar following treatment with radiation and Temodar is recommended for patients with methylated and unmethylated glioblastoma. Final Result: The reviewer determined that the equipment at issue was 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 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: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested for intensity modulated radiation therapy (IMRT) for treatment of her leiomyosarcoma of the retroperitoneum. Findings:  Two physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) Practice Guidelines for retroperitoneal soft tissue sarcoma, options regarding primary treatment for patients deemed unresectable include chemotherapy, radiotherapy, or palliative surgery for symptoms.  The purpose of this is to downstage following response to allow for resection.  Under the principles of radiation therapy, pre-operative radiation therapy, delivering approximately 50Gy of external beam radiation therapy is recommended followed by surgery. Radiation boosts could be considered whenever feasible for positive or close margins. Furthermore, the specific guidelines for radiation therapy specify that sophisticated treatment planning with IMRT and protons can be used to improve the therapeutic effect.  If an R1 or R2 resection is anticipated, clips to high risk areas for recurrence is encouraged.  In addition, the guidelines state that radiation therapy does not substitute for sub-optimal surgical resection and the total doses should always be determined by normal tissue tolerance.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 8-year-old male enrollee has requested  24 additional speech therapy sessions for treatment of the enrollees expressive language delay and articulation disorder. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. The medical literature supports the necessity and effectiveness of speech therapy in children with articulation and speech dysfunction. In this case, the patient is noted to have had a significant delay in the acquisition of language since he was 22 months old. He has received speech therapy, at least one hour per week, since the initial diagnosis. The initial diagnosis was expressive language disorder, but subsequently the diagnosis evolved to a severe articulation disorder. At the age of 5 years and 8 months, utilizing the Goldman Fristoe Test of Articulation he was at the 3rd percentile for his age. With weekly speech therapy he has made significant improvement in articulation. Since that testing his speech therapy has been directed toward eliminating his articulation problems. In addition, his therapist has been goal-directed toward these specific deficits. His therapist has recognized his problems and has specifically directed his therapy to correct the articulation errors. Thus, it is medically necessary for this patient to receive 24 additional speech therapy sessions. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested acupuncture for the treatment of her post-surgical pain. Findings:  The physician reviewer found that there is no conclusive evidence in the medical literature documenting the effectiveness of acupuncture for post-operative pain. The medical literature does document that acupuncture and transcutaneous electrical stimulation have some benefit in decreasing symptoms of nausea. The adjuvant use of acupuncture for treatment and management of post-operative pain is recommended if conventional pain management treatments fail or there are severe adverse side-effects of such conventional treatments. However, in this case, the records do not document trials and failures of conventional pain management therapy or contraindications to such therapies. A study by Usichenko and colleagues concluded that the evidence that auricular acupuncture reduces post-operative pain is promising but not compelling. A study by Ernst found that the medical conditions that were improved by the use of acupuncture included chemotherapy-induced nausea and vomiting, post-operative nausea and vomiting and idiopathic headache. That study concluded, Cochrane reviews of acupuncture do not suggest that this treatment is effective for a wide range of conditions. All told, there is a lack of scientific evidence supporting the benefit of acupuncture in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging/magnetic resonance angiogram (MRI/MRA) for evaluation of her medical condition.  Findings:  The physician reviewer found that thoracic outlet syndrome (TOS) refers to a group of clinical syndromes caused by congenital or acquired compression of the brachial plexus (neurogenic TOS) or subclavian artery or subclavian vein as they pass through the thoracic inlet.  There are multiple modalities utilized to diagnose TOS. These include ultrasound, plain radiographs, contrast-enhanced computed tomography (CT), MRI, or conventional angiography. MRI has become popular in its ability to simultaneously demonstrate the vasculature, bones, and soft tissues, in multiple different projections. As noted by Demondion and colleagues The thoracic outlet includes three compartments (the interscalene triangle, costoclavicular space, and retropectoralis minor space), which extend from the cervical spine and mediastinum to the lower border of the pectoralis minor muscle. Dynamically induced compression of the neural, arterial, or venous structures crossing these compartments leads to thoracic outlet syndrome (TOS). The authors further state that clinical diagnosis is often difficult and that MR imaging remains the method of choice when searching for neurologic compression. Aghayev and Rybicki concur stating The use of contrast-enhanced [three-dimensional] 3D MRA provides comprehensive information on arterial and venous compression by surrounding organs. In this case, the patient has previously undergone extensive evaluation and has tried multiple conservative therapies. The vascular surgeon has elicited evidence of vascular compromise (decreased radial pulses and bruits) with changes in position. In this clinical setting it is medically necessary to investigate the anatomy and determine whether surgery is an additional viable option. Based on the peer-reviewed literature and clinical documentation, the requested services are clinically indicated for this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in diagnostic radiology 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 parent of an 11-year-old male has requested Amitiza for treatment of his constipation.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  As noted by Coccorullo and colleagues, the recommended treatment of childhood constipation includes education, disimpaction, and maintenance therapy, consisting of use of laxatives, dietary changes, and behavioral modification.  Per Bove and colleagues, there is a lack of evidence indicating that increasing fluid intake and physical activity relieves the symptoms of chronic constipation.  The authors noted that patients with normal-transit constipation should increase their fiber intake through their diet or with commercial fiber.  Per the authors, osmotic laxatives may be effective in patients who do not respond to fiber supplements, and stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives.  The current medical evidence does not support the requested medication in this clinical setting.  Amitiza is indicated for treatment of constipation in adults.  Additionally, the medical records do not document intolerable side effects to fiber-bulk forming agents and to hyperosmotic agents.  All told, Amitiza is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested acupuncture for treatment of her polymyositis.  Findings:  The physician reviewer found that there is a paucity of evidence supporting the use of acupuncture for the treatment of polymyositis (Firestein, et al). The standard treatment for polymyositis includes corticosteroids and if necessary, steroid-sparing agents such as methotrexate. Specifically, there are no reliable, randomized, clinical trials demonstrating the efficacy of acupuncture in the treatment of this disease. For these reasons, the requested acupuncture treatment is not medically necessary for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for arthroscopic hip surgery for labral tear, loose body removal and chondroplasty. Findings:  Three physician reviewers found that the medical literature does not support the superior efficacy of the services at issue in this clinical setting. The published studies available are generally retrospective in nature with very few being well-controlled. Although there is some evidence suggesting short to medium term benefit, there is a lack of long term follow-up evidence to determine impact, if any, on osteoarthritis progression. Hip arthroscopy in presence of degenerative changes in excess of grade one is of questionable benefit. In addition, evidence supporting surgery for femoral-acetabular hip impingement is somewhat uncertain at best. The studies indicate that hip replacement surgery is the standard treatment option in this clinical setting. Therefore, arthroscopic hip surgery for labral tear, loose body removal and chondroplasty was not likely to have been more effective than the available treatment option of treatment this patient. Final Result: 2 of 3 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 physician reviewers 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: An enrollee has requested Armour Thyroid medication for treatment of the enrollees thyroid cancer status post thyroidectomy.  Findings: The physician reviewer found that the patient has a history of hypothyroidism. The patient was managed with levothyroxine (T4) and Cytomel (T3) in the past, but reports sub-optimal efficacy on these medications. In the medical literature, levothyroxine has remained the standard of care for treatment of patients with hypothyroidism (Jonklaas, et al). In spite of this, some patients prefer to take desiccated thyroid preparations, such as Armour Thyroid. However, while desiccated thyroid does contain both T4 and T3, the balance of T4 and T3 can lead to non-physiologic levels of thyroid hormones. Further, the amounts of T4 and T3 can vary in each batch of desiccated thyroid, thereby making it more difficult to maintain steady blood levels of the hormones. Given these findings, the requested Armour Thyroid medication is not medically necessary for treatment of this patients hypothyroidism.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 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: Upheld

The parent of a three-year-old female enrollee  requested psychiatric intensive outpatient program (IOP) service for medical treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that there is a lack of clinical documentation with regard to the indicated autism progress report, which included revised treatment goals and specific recommendations that suggest the most recent clinical interventions have been insufficient and requires a higher level of care to achieve therapeutic success. In addition, the diagnoses of mood disorder and generalized anxiety disorder, which are conditions that may be appropriate for IOP level of care in context of suboptimal response to outpatient services, are not substantiated in the documentation provided. Therefore, based on the clinical documentation and medical literature cited above, the request for psychiatric IOP services are not medically necessary for treatment of the patients medical condition.