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

The parent of a two-year-old male has requested  coverage for speech therapy at a frequency of two sessions per week for one hour per session for treatment of his speech delay.  Findings:  The physician reviewer found that this nearly three-year-old patient has no speech. The available studies indicate that the patient is functioning in a moderate developmental delay category (scores ranged from the 9th to the 45th percentile for age in various developmental categories.) The common practice of the medical community, for a non-verbal child who does have the potential for speech development, would be to prescribe speech therapy. There is a robust body of medical literature supporting the need for speech therapy in this speech delayed population. A paper by Law et al. reports that children with speech delay can be readily treated, as confirmed by a meta-analysis of multiple medical journal articles. Goorhuis-Brouwer, et al. specifically examined speech-delayed normal and abnormal intellect children and found that both groups are candidates for successful speech therapy. Reports by Emmanues and Buschman describe two-year-olds who tested below the 10th percentile for age in both receptive and expressive language and benefitted from speech therapy in prospective studies. Thus, the literature is replete with support for the use of speech therapy in the speech delayed two-year-old population. While speech therapy is a medically necessary modality for this patient, the submitted documentation does not support two hourly sessions of speech therapy per week at this time. The patient should receive one hour weekly of individual speech therapy. The patients progress toward goals should be documented and he should be reassessed in six months to determine the need for continued therapy.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patients parent has requested reimbursement for vitamin D testing (CPT 82306). The American Academy of Pediatrics (AAP) has published guidelines on vitamin D supplementation and testing to optimize bone health in children and adolescents (Golden, et al.). The AAP guidelines include updated allowances for calcium and vitamin D, along with recommendations for supplementation and weight-bearing activities. The AAP currently endorses the higher recommended dietary allowances for vitamin D advised by the Institute of Medicine and supports testing for vitamin D deficiency in children and adolescents with conditions associated with increased bone fragility. Further, the AAP noted that, Universal screening for vitamin D deficiency is not routinely recommended in healthy children. This patients records document that the patient presented with abdominal pain and diarrhea. The patients provider recommended laboratory testing including vitamin D assessment. However, the records provided for review do not document that the patient was at risk for vitamin D deficiency to meet an indication for testing. Therefore, the vitamin D testing (CPT 82306) was not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 30-year-old male enrollee has requested authorization and coverage for Mekinist 2 mg. As noted in the medical literature, the safety and effectiveness of MEK inhibition in thymic carcinoma has not yet been demonstrated in clinical trials. In addition, the use of molecular profiling for guiding treatment for thymic carcinoma remains unknown. Overall, standard therapies such as immunotherapy have been shown to be more effective in this clinical setting. In a phase II study, researchers reported on 40 patients with stage IV thymic carcinoma and at least one prior line of systemic therapy. The patients were treated with pembrolizumab for up to two years. There were nine objective responses, including one complete response. All told, the requested Mekinist 2 mg is not supported as medically necessary for treatment of this patients thymic carcinoma. 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 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: Upheld

A 60-year-old female enrollee requested authorization and coverage of extracorporeal shock wave therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees heel pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee requested authorization and coverage of the medication Viagra for the treatment of erectile dysfunction.  The health plan denied the enrollees request indicating that Viagra is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a cervical spine magnetic resonance imaging (MRI). Cohen notes that MRI is characterized by a high prevalence of abnormal findings in asymptomatic individuals but may be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment. In this case, the patients reported widespread pain symptoms in the head, neck, upper back, low back and upper and lower extremities do not correlate with a cervical anatomic source. The submitted records indicated that they had been evaluated by multiple specialists. While a letter from the patients chiropractor recommends a cervical spine MRI, the records do not document this recommendation by any of the patients other medical providers. Given that the submitted documentation indicates widespread nonanatomic symptoms that do not correlate with a cervical spinal source, and are without red flags of serious cervical pathology, the requested service is not medically indicated. Therefore, a cervical spine 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 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: Experimental/Investigational
Decision: Overturned

A 43-year-old male enrollee has requested Rituximab infusions for the treatment of his progressive polymyositis. Findings:  Three physician reviewers found that the patient has a severe disease, polymyositis, that has not been responsive to standard therapies. Several articles have been published in peer-reviewed journals documenting a favorable response to Rituximab in similar patients. The patient appears to be an appropriate candidate for Rituximab. Given the failure of standard treatments in this case, the use of Rituximab is medically reasonable and appropriate option. In fact, the submitted documentation demonstrates the patient has already benefitted from a trial of the therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested for vancomycin and ceftriaxone for treatment of his condition of a central nervous system infection. Findings:  The physician reviewer found that there is substantial evidence in the records provided that this patient does not have neurosyphilis, and there is no evidence that he has any infection involving his brain or meninges. It would not be appropriate to treat this patient with vancomycin and/or ceftriaxone.  Vancomycin may be associated with nephrotoxicity, and ceftriaxone is also associated with side effects.  All told, there is no evidence that this patient has any infection that should be treated. Therefore, vancomycin and ceftriaxone are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested the MiniMed 530G with Enlite (E0784, A9277, and A9276) for medical treatment of her type 1 diabetes.   Findings:  The physician reviewer found that this patient has longstanding type 1 diabetes mellitus with poor glycemic control, unstable blood glucose levels with large glycemic fluctuations, and wide fluctuations in preprandial blood sugars as well as hypoglycemia. Her provider has recommended she switch from conventional insulin injections to an insulin pump. Based on the available medical records, the requested equipment including the MiniMed 530G with Enlite (E0784, A9277, and A9276) is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA). Applying the recommendations from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), additional testing for the presence of community acquired pneumonia (CAP) may be indicated for patients who present with signs and symptoms concerning for respiratory disease. This patients records do not document symptoms concerning for respiratory disease or exposure to a pathogen to support the testing performed. Moreover, the performance of this assay has not been validated in clinical settings. The standard of care in this patients preoperative assessment would include blood testing and cultures. Given these findings, the laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in infectious disease 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 parents of a five-year-old male enrollee requested authorization and coverage of continued speech therapy for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees delayed speech.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee requested authorization and coverage of the medication celebrex for the treatment of osteo arthritis.  The health plan denied the enrollees request indicating that celebrex is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for orthoptic and pleoptic training with medical direction that was provided and future services. The Health Plan has denied this request, indicating that the services at issue were and are considered experimental or investigational for treatment of the enrollees convergence insufficiency.Findings:  Two out of three physician reviewers found that there is a lack of consensus regarding appropriate treatment for CI. In a comparison of three treatment approaches, a conclusion was drawn that using multiple methods to treat convergence insufficiency results in more effective orthoptic therapy. Researchers concluded that vision therapy is effective in recovering from symptomatic CI. However, these studies lacked a control group. Overall, there is a lack of scientifically valid studies of the treatment of CI. Home-based therapies and observation for CI are the prevailing treatment options due to the lack of evidence for, and standardization of, office-based treatments. One physician reviewer found that given that this patient was still symptomatic despite home exercises, a trial of office-based orthoptic exercises is warranted.Final Result: The reviewers determined that the services at issue were not and 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 ophthalmology 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

A 29-year-old male enrollee has requested DNA sequencing provided for evaluation of his colon adenocarcinoma.  Findings:  The physician reviewer found that DNA sequencing of solid tumors to screen for genetic mutations that are potential targets for known therapies is a promising concept, but at this time is not considered a standard of care. This patient has Stage IIIb colon cancer, for which standard therapy following surgery is a course of adjuvant chemotherapy with the FOLFOX regimen. The results of FoundationOne testing would not have an impact on the patients therapy or risk for recurrence. Overall, there is only anecdotal data available to suggest that the assay has any clinical value over standard therapies specified in the evidence-based guidelines. Consistent with these findings, the testing at issue was not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee has requested a mandibular repositioning device and services for the treatment of his sleep apnea. Findings:  The physician reviewer found that CPAP is considered the gold standard for treatment of obstructive sleep apnea. However, CPAP only has a 50 to 70% compliance of patient use despite its effectiveness, indicating that a significant subset of patients cannot tolerate its use. For these patients, alternative therapies are available. One of these treatments is the use of an anterior mandibular positioning oral device for those patients where anterior positioning of the mandible eliminates the obstruction of the airway and thus reduces or eliminates apnea episodes. There are many studies in the literature which have demonstrated the safety and efficacy of these oral anterior mandibular positioning devices in 40 to 50 % of selected cases. Like CPAP many patients are not able to tolerate these devices due to TMJ joint pain, sore teeth, xerostomia, etc. However, for those individuals who are unable to tolerate CPAP it offers an alternative non-surgical treatment. Surgical treatments include nasal surgery, palatopharyngoplasty and othognathic surgery to move the mandible and/or maxilla forward depending on the site(s) of the airway obstruction.  However, all of these surgical treatments are associated with significant risks and adverse side-effects. The patient has signed an affidavit that he was unable to tolerate CPAP (which is patient-dependent and known to occur in 30 to 50% of patients treated with CPAP). The intra-oral mandibular anterior positioning device, is a medically acceptable alternative treatment. Therefore, the anterior mandibular positioning device was medically necessary in this case, and an acceptable alternative treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested osteochondral allografting for the treatment of her left knee problems. Findings:  Two physician reviewers found that in this instance, osteochondral allografting of the medial femoral condyle is preferable to knee replacement given the patients young age and her high activity level.  Other compartments are relatively spared and asymptomatic.  Additionally, she has normal alignment and an intact medial meniscus and no evidence of inflammatory disease.  She is a good candidate for osteochondral allografting of the medial femoral condyle.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech disorder. Findings:  The physician reviewer found that this patient is a young preschool-aged child with neuro-oral-muscular dis-coordination resulting in a severe stuttering disorder. Some theorists consider stuttering to be the result of subtle neuron-physical dysfunctions resulting in disruption of the precision needed to produce speech. Stuttering, or speech dysfluency may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma. Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously. However, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category. They require therapy and counseling in order to recover from the disorder. For this latter group, if therapy is started early, the prognosis is favorable. It is important for clinicians to know when to refer for therapy. In general, referral is indicated if the child is over four-years-old, has been stuttering for more than three months, shows consistent stuttering and demonstrates tension or struggle behavior when stuttering (Lawrence and Barclay). Therapy is considered to be more effective if started before the age of five years (Ward). In the case of this patient, given the underlying neuro-oral-muscular dis-coordination and severity of his symptoms, his chances of spontaneous recovery are small. Aggressive speech therapy offers him the best chance of full recovery. Speech therapy was therefore appropriate and medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement for residential treatment center services. This patient was admitted with a history of cannabis use as well as recent suicidal ideation. The progress notes indicate that the patient was not exhibiting withdrawal symptoms during the disputed timeframe. The patient did not report significant medical issues. He did not engage in self-harm behaviors during the admission. The patient expressed motivation for treatment. He demonstrated an understanding of struggles with substance use and was insightful in therapy sessions. The records indicate that the patients overall function was good. There was no indication of problems with activities of daily living. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation with any active intent or plan. With regards to functional status, the records support a score of 2 due to overall good functional level in treatment but consideration of family relationship issues when in the community and using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of cannabis use that appeared to be under adequate control and was not adversely affecting treatment to a significant degree. In terms of level of stress of the recovery environment, the records support a score of 2 due to a stable living environment. With regards to level of support of the recovery environment, the records support a score of 2 due to supportive resources who were willing to provide aid in times of need. In terms of treatment and recovery history, the records support a score of 3 due to current motivation for treatment but no past significant sobriety with consideration of minimal past substance use or mental health treatment. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 15. This score correlates with high intensity community-based services. Therefore, residential treatment center services were not medically necessary for the 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 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 54-year-old male enrollee has requested back surgery (laminectomy) for the treatment of his leg and back pain. Findings:  The physician reviewer found that this patient has multiple level degenerative changes noted on the CT myelogram. He is status post L5-S1 laminectomy. The patient has persistent low back pain and right lower extremity pain postoperatively. No provocative studies such as lumbar discography have been performed that might help to localize the symptomatic level in the lumbar spine. Neurodiagnostic studies did not confirm the presence of radiculopathy. There is no record of facet blocks and/or epidural steroid injection which could provide both diagnostic and therapeutic benefit. All told, a laminectomy at L4-5 is not medically indicated or necessary on the basis of the patient's clinical signs and symptoms, CT myelogram findings and normal neurodiagnostic studies.