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

Physician 1: The patient is a 57-year-old man with a lesion in the talus. A request has been made for an osteochondral allograft transfer system (OATS) procedure. The Health Plan has denied authorization for the proposed procedure on the basis it is considered investigational for repair of an ankle joint.The OATS procedure has been very successful in the knee and recently has been utilized in the ankle for situations such as these. There are no other options for the patient; the procedure is likely to provide pain relief and help to prevent the need for fusion. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: This patient is a 57-year-old male with an osteochondral lesion of the right medial talar dome, which is greater than 1 cm in size. The patients provider has recommended an osteochondral allograft transfer system (OATS) procedure. The Health Plan has denied authorization for an OATS procedure on the basis that it is considered experimental.There is sufficient data to support the OATS procedure in the talus for lesions greater than 1 cm such as the one involved in this case. There is also ample short-term ankle literature supporting the OATS procedure. Given the large size and advanced stage of the patients lesion, he is an excellent candidate for the OATS procedure. The requested procedure is likely to provide the best chance of a positive outcome for this patient. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 57-year-old male with a significant osteochondral lesion in the talus from which the patient is very symptomatic. It has been recommended the patient undergo an osteochondral allograft transfer system (OATS) procedure. The Health Plan has denied authorization for the requested procedure on the basis it is not likely to be effective in patients such as this patient.The talar lesion will most likely lead to significant arthrosis of the ankle from which the patient will likely experience pain, stiffness and disability. Drilling and bonegrafting are associated with unpredictable results that are usually far from satisfactory outcomes. Osteochondral bone grafting is the only procedure that has a reasonable chance of restoring articular integrity. Ankle fusion is a major operation with significant morbidity that does nothing to preserve or restore function. Since the OATS procedure has the greatest likelihood of restoring normal ankle function, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion surgery. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents now eight years status post L5-S1 decompression and instrumented fusion. The enrollee reportedly did well following surgery, until approximately one year ago, with gradual development of low back pain exacerbated with motion. The enrollee has persistent severe pain and difficulty in activities of daily living. Her pain is relieved in the supine position and worsened with sitting or standing for prolonged periods. Conservative treatment has included activity modification, physical therapy and injection therapies, without sustained improvement. However, there is no imaging evidence (x-ray, MRI or CT) of pseudoarthrosis, hardware failure, or segmental instability to support the medical necessity of surgical intervention at the L5-S1 level. There is no documentation of a positive diagnostic hardware block to support hardware as the pain generator. There is no compelling rationale presented to support the medical necessity of the requested revision lumbar fusion request in the absence of documented hardware failure, pseudoarthrosis, or segmental instability. Therefore, the requested lumbar spinal fusion surgery is not medically necessary for the 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene expression test. Findings:  The physician reviewer found that records document that this patient presented with a diagnosis of malignant melanoma. According to the National Comprehensive Cancer Network (NCCN) guidelines, a melanoma with Breslow depth of 0.5 mm is clinically stage 1A. Even if the melanoma is slightly thicker, the melanoma was likely smaller than 0.8 mm with no ulceration, which is consistent with stage 1A. The treatment for this stage includes wide local excision. Swetter and colleagues noted that routine molecular testing, including gene expression profiling with DecisionDx-Melanoma is discouraged until better use criteria are defined. Treatment of thin melanomas measuring between 0.5 mm to 0.8 mm Breslow depth without evidence of ulceration, are treated with wide local excision per NCCN guidelines. Therefore, the DecisionDx-Melanoma gene expression test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma gene expression test 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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: Experimental/Investigational
Decision: Upheld

A 57-year-old male has requested proton beam radiation therapy for treatment of his adenocarcinoma of the prostate.   Findings:  Three physician reviewers found that the patient has a recent diagnosis of low-risk, early-stage prostate cancer.  Per the medical records, his pretreatment prostate specific-antigen (PSA) was 4.1, and core biopsy demonstrated Gleason 6/10 adenocarcinoma involving 4 of 7 cores from the right side.  The use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability. Certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies, are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue.  Proton beam radiation therapy is an accepted, safe and effective treatment modality for prostate cancer.    However, the current medical literature has not demonstrated the superior efficacy of proton beam radiation therapy in this clinical setting.  Vargas and colleagues noted that proton beam radiation therapy yielded improved normal tissue sparing as compared to intensity modulated radiation therapy.  However, other accepted technologies, such as image-guided radiation therapy, with daily CT, and imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing, and these technologies were not investigated in that paper.  Some assert that that proton therapy could lower the risk of second radiation-associated malignancies.  However, there is a lack of published clinical data that demonstrate this.  Thus, the superior effectiveness of proton beam radiation therapy over intensity modulated radiation therapy in reducing radiation-associated malignancies has not been established.  In sum, there is a lack of data demonstrating that proton beam radiation therapy is likely to be of greater benefit than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested for speech therapy services in a small group setting, physical therapy services and occupational therapy services for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the medical literature strongly supports speech therapy in patients with articulation defects. Papers by Tyler and Sharp and Hillenbrand state that reviews of the literature indicate the necessity and effectiveness of speech therapy in children over the age of three with articulation defects. The report of the Speech and Language Association states that all autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. In accordance with the occupational therapy evaluation findings, the patients delays are not severe enough to warrant the need for occupational therapy at this time. The recommendation of physical therapy was for a right foot sprain and the physical therapy treatment plan indicated weekly therapy. However, many months have elapsed since the initial recommendation and there is no indication that the patient continues to experience functional difficulties secondary to the foot sprain. Therefore, the requested physical therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for substance abuse residential treatment center (RTC) services.Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Applying the CALOCUS criteria, the substance use RTC services were not and are not medically necessary for treatment. The patient presents a composite score of 18, which correlates with intensive outpatient services. Given these findings, the substance use RTC services were not and are not medically necessary for treatment of this patient behavioral health issues. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma Gene Expression Classifier test performed for the evaluation of the enrollees thyroid nodule. Findings: Three physician reviewers found that the Afirma Gene Expression Classifier test performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The cytopathology of the 3.6 cm thyroid nodule was consistent with atypia of undetermined significance. The risk of malignancy is 5-15% in atypia of undetermined significance (Cibas, et al; Haugen, et al). The American Thyroid Associations guidelines for nodules with atypia of undetermined cytology state that investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. If genetic testing is suspicious, the risk of malignancy increases to 40% (Haugen, et al; Alexander, et al). In this case, the result of the Afirma Gene Expression Classifier was suspicious for malignancy. This information was important to determine the decision whether to perform thyroidectomy, and the extent of surgery. There are multiple peer reviewed scientific articles supporting the benefits of the genetic test in thyroid nodules (Cibas, et al; Haugen, et al; Alexander, et al). In conclusion, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was 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 number are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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 an esophageal sphincter augmentation device (LINX) procedure for treatment of his medical condition.  Findings:  Two physician reviewers found that the LINX procedure is not likely to be more effective for this patient than other available treatment options. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. The evidence review by Sheu and Rattner concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current GERD therapies, remains to be determined. The available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment such as surgical fundoplication (Sheu, et al). Based on current literature, LINX is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her status post silicone breast implant placement.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure in this patients case.  There is a lack of physical findings or documented clinical suspicion suggesting rupture.  The Health Plan has offered evaluation with mammogram and ultrasound, which is the appropriate first-line of accepted imaging in this clinical setting.  There is a lack of support for the requested breast MRI in this case.  If evaluation with mammogram and ultrasound are non-diagnostic or equivocal, then further evaluation with breast MRI may be considered.  However, absent evaluation with these accepted first-line imaging modalities, the medical necessity of the requested breast MRI cannot be established.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested a full body scan for evaluation of her history of aphasia and gait difficulty.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure in this case.  This patient has a history of progressive expressive aphasia.  The documentation does not indicate a prior history of malignancy, so primary or metastatic disease is not mentioned as a clinical possibility.  This patient has a progressive neurogenerative process as documented in the medical records.  However, the medical records do not demonstrate the rationale behind the requested full body scan for the evaluation of this patient with no history to suggest malignancy or possible occult infection.  The clinical notes do not provide support for the requested full body scan.  All told, the requested full body scan is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Linzess capsules. Findings: A study noted that Linzess has a novel mechanism of action, resulting in accelerated intestinal transit and is indicated for treatment of constipation-predominant irritable bowel syndrome (IBS-C). Another study noted that linaclotide may be recommended for step-up management of IBS-C. Guidelines recommend linaclotide for overall symptom improvement in IBS-C patients. In this case, the patient has a diagnosis of IBS-C. The records show that the patient has used Linzess previously, with good results. Therefore, Linzess capsules are 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 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 40-year-old male enrollee has requested continued inpatient acute rehabilitation for the treatment of his traumatic brain injury. Findings:  The physician reviewer found that this patient requires multidisciplinary/interdisciplinary team rehab with doctors, nurses, social workers, and physical, speech, and occupational therapists. Although this patient initially progressed slowly, he has made good progress in all areas (mobility, ADLs, cognition). He has not reached his maximal therapeutic benefit as of yet and therefore requires additional inpatient acute rehabilitation services.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-month-old male enrollee requested a cranial DOC band for medical treatment of the enrollees plagiocephaly.  Findings:  The physician reviewer found that the requested cranial DOC band is not reconstructive in nature and not medically necessary for this patient. Clinical orthotic devices are not considered medically necessary in infants with mild to moderate plagiocephaly. According to the documentation provided, this patient has mild to moderate left plagiocephaly. Mortenson and colleagues reported that the data supports the use of repositioning in young infants and the start of orthotic helmet treatment for infants with significant deformational plagiocephaly at four to six months. The authors concluded that further research is needed to better understand the parameters for use, long-term outcomes, and natural history on the impact on caregiving. Thus, the cranial DOC band is not expected to provide a more than a minimal improvement of the appearance of the patient. All told, the medical records do not support the medical necessity of the requested DOC band for treatment of this patients mild to moderate left plagiocephaly.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 22-month-old female enrollee has requested coverage for speech therapy  for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy has been found to be efficacious in the treatment of speech delays in young children.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested functional foot orthoses for the treatment of her foot problems. Findings:  The physician reviewer found that the patient has tried an over-the-counter arch support which did not help her condition. She is attempting to avoid surgery. The patient seemed to have experienced considerable relief of symptomatology with custom made orthotics. The Health Plan states that coverage for custom made orthotics is included once over-the- counter orthotics have failed. The enrollee seems to have fulfilled that requirement. Custom made orthotics are within the spectrum of non-operative treatment for hallux rigidus. The requested medical equipment is medically indicated for treatment of this patient.