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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the enrollees breast cancer screening.  Findings: Two physician reviewers found that the patient with bilateral screening mammogram with digital breast tomosynthesis was denied reimbursement for the digital breast tomosynthesis portion of the examination. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Therefore, the medical literature supports the use of digital breast tomosynthesis over standard mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Two reviewers determined that the service 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 overturnedCredentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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 patient is a 12-year-old male with short stature, who had been growing clearly below the 3rd percentile prior to the initiation of therapeutic growth hormone at the age of eight years. The therapy has continued and he is followed by a pediatric endocrinologist. An interval note dated January 2006 indicated a height of 140.1cm (11th percentile) with a bone age appropriate for his chronological age. Before growth hormone therapy was begun the patient had two IGF-1 levels in the low and very low normal ranges. The endocrinologists letter indicated that an MRI was planned, but there is no record of this in the material submitted. The parents request for continued authorization and coverage of growth hormone therapy was denied by the Health Plan based upon a determination that the therapy is not medically necessary.It is probable that this patient has a growth hormone deficiency. Prior to the initiation of growth hormone therapy he had repeatedly low IGF-1 levels with no other identified cause for his short stature and retarded bone age.  Following the initiation of growth hormone therapy both his bone growth rate and his IGF-1 levels were normalized. In light of the patients response, he should continue to receive growth hormone and see his endocrinologist regularly to ensure that no side effects have developed and that he continues to have a positive growth response to the therapy. Follow up regarding the MRI of the brain is also important.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, breast tomosynthesis revealed an interval change when compared to prior studies. Areas of asymmetry are better evaluated with tomosynthesis than with conventional 2D mammography. As such, the tomosynthesis at issue was helpful for evaluation in this clinical setting. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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 25-year-old male enrollee requested substance abuse inpatient detoxification services for medical treatment of his opiate dependency.  Findings:  The physician reviewer found that the patient presented in a moderate state of withdrawal evidenced by a clinical opiate withdrawal scale (COWS) score of 15. Overall, there was no indication that he was at imminent risk of severe withdrawal. He was not suicidal or homicidal and had no history of self-harming behaviors. He had no medical or psychiatric comorbidity.  He was motivated and cooperative with treatment.  With the Subutex protocol, the patients COWS score dropped to five to zero the same day. Applying the American Psychiatric Association (APA) guidelines, this patient was a candidate for detoxification in an outpatient setting. Thus, substance abuse inpatient detoxification services was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested bilateral total hip arthroplasty for the treatment of her osteoarthritis and vascular necrosis. Findings:  The physician reviewer found that total hip arthroplasty is a well-proven and appropriate procedure for significant hip arthritis. However, while this patients diabetes is not likely a contraindication to the procedure, her current weight may be considered as such. Biomechanical studies have shown that the forces in the hip joint generated by walking are 2.5 times a patients body weight, and the patients current weight will likely place additional stress on the hips. The literature does not specifically list obesity as a contraindication to the procedure, however it is unreasonable to expect the results of the arthroplasty to last in terms of longevity and an individual of this patients age is likely to require several revisions without loss of excess weight prior to surgery. Thus, while the patient does require surgery, and the requested procedure is appropriate, she must first lose weight in order for the results to be worthwhile. While there are no absolute guidelines regarding a patients weight prior to hip arthroplasty, for a patient of this height, a weight reduction to 200 pounds with maintenance over time would be consistent with generally accepted standards in this setting.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-month-old male enrollee has requested physical therapy (PT) for treatment of the enrollees gross and fine motor delays. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested physical therapy. The patient was evaluated by a physical therapist at 10 months and utilizing the Peabody Developmental Motor Scales the patient had motor delays between 32 to 40% of anticipated age levels. Moreover, the lack of a specific diagnosis should not delay physical therapy for this patient as the ultimate diagnosis may take sophisticated genetic, electromyelographic and imaging technology to determine whether the disorder is in the lower motor neuron or the upper motor. The present diagnosis is congenital hypotonia and this diagnosis is well-established in the peer-reviewed literature as a catch-all diagnosis for this age group. Thus, it is medically necessary that this patient receive physical therapy as recommended by his pediatric neurologist. The patient will benefit from physical therapy while awaiting a more exact neuromuscular diagnosis. Based on the medical literature cited above and the documentation submitted for review, the requested physical therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for high frequency chest wall oscillation air pulse generator for treatment of the enrollee who has a history of asthma and Downs syndrome. Findings:  2/3 of the physician reviewers found that there is minimal evidence that the use of chest wall percussive devices benefit patients with non-cystic fibrosis bronchiectasis. There are indications for a high frequency chest wall oscillation system including cystic fibrosis, bronchiectasis, or neuromuscular disorder with inability to clear secretions. While this patient has recurrent infections per the documentation provided, there is no evidence that the patient has underlying bronchiectasis, cystic fibrosis or a neuromuscular disorder that alters airway clearance. There is no evidence of an airway disorder (primarily bronchiectasis) without documentation of pulmonary function testing (evidence of airway obstruction) or chest imaging (evidence of recurrent infection). There is also a lack of documentation noting that basic techniques such as postural drainage were tried prior to use of chest wall percussive devices. A combination of medications, chest physiotherapy, cough assist accessories, plus special coughing positions and techniques should be attempted prior to using chest wall percussive systems. In sum, due to a lack of support in the medical literature for the requested equipment, the high frequency chest wall oscillation air pulse generator provided was not and is not likely to have been superior over other modes of therapy available for treating this patient.  Final Result: 2/3 of the reviewers determined that the requested equipment was not and 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

An 18-year-old female has requested biofeedback with physical therapy for treatment of her reflex neurovascular dystrophy and complex regional pain syndrome.   Findings:  The physician reviewer found that based on review of the available records, biofeedback as a treatment adjunct is medically appropriate for treatment of this patients medical condition. Complex regional pain syndrome is a heterogeneous disorder that is a neuropathic pain disorder. The most appropriate management of complex regional pain syndrome is by multidisciplinary approach with the inclusion of medical and psychological intervention as well as physical and occupational therapy. The medical records provided for review indicate that while the patient has had improvement with her ongoing therapy, she has not reached the point of maximum improvement. In addition, psychological therapy such as biofeedback and cognitive behavioral techniques which target pain, stress and mood disorders are valuable adjunctive treatments for this condition and can facilitate functional improvement. As such, biofeedback as a component of her pain treatment is medically appropriate for the treatment of complex regional pain syndrome. In general, biofeedback sessions are provided with a number generally of 10 to 20 sessions, with an initial series of 10 treatments, and additional treatments provided as needed by evaluating the patients objective functional gain. Biofeedback is a therapy provided within the context of interdisciplinary pain management treatment programs. As published by Bruehl and Chung, the psychological and behavioral aspects of complex regional pain syndrome support that psychological components of treatment are important for patients with complex regional pain syndrome. Moreover, Chung Yung and Bruehl noted that multidisciplinary, interdisciplinary treatment of complex regional pain syndrome is the optimal treatment paradigm and that by psychological therapy such as biofeedback and cognitive behavioral techniques, are valuable adjunctive treatments for pain control to facilitate functional improvement. All told, the requested biofeedback with PT is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested coverage for speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the role of speech and language therapy in autistic spectrum disorders is well discussed in the medical literature. Numerous publications, including those cited above, recommend or demonstrate evidence for speech and language therapy for children with autism. While there have been few studies offering a direct comparison of methods, many experts believe that children with autism benefit from intensive, early intervention which focuses on increasing the frequency, form, and function of communicative acts. Paul noted in his study that intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old male enrollee has requested inpatient detoxification services for the treatment of his substance abuse disorder. Findings:  The physician reviewer found that the detoxification services at issue were medically necessary. The patients family initiated the admission to the detoxification program in response to the patients threatening behavior which required police intervention. At the time of discharge from the detoxification program the patient was reported to have poor insight into his issues with substance abuse and on mental status examination, it was found that he rambles and is tangential. There were also concerns about the patients judgment and his potential to be harmful to himself or others. As a result, after he was treated in the detoxification program at issue, he was admitted to a 30-day inpatient treatment substance use disorder program, followed by a four-month stay in a sober living facility. Given this patients significant history of polysubstance abuse, threatening behavior, and the risk of harm he posed to himself and others, it was medically appropriate to admit this patient to a detoxification level of care.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for Valtoco (diazepam 5 mg nasal spray). Connolly describes Dravet syndrome as one of the most severe epilepsy syndromes of early childhood and explains that it is associated with mutations in the sodium channel alpha1 subunit gene (SCN1A) in 70% to 80% of individuals, resulting in inhibition of the GABAergic inhibitory interneurons and leading to excessive neuronal excitation. Shmuely and colleagues report that Dravet syndrome is characterized by high epilepsy-related premature mortality and a marked young age at death. The authors further reported that in 177 published cases of death in children with Dravet syndrome, 56 deaths (or 32%) were a result of status epilepticus, and that 73% of the deaths occurred before age ten.  Cloyd and colleagues note that seizure clusters must be treated quickly and effectively to prevent progression to prolonged seizures and status epilepticus. The authors further note that rescue therapy for seizure clusters focuses on the use of benzodiazepines. The authors found that the diazepam nasal spray safety profile is consistent with that expected for rectal diazepam, with low rates of nasal discomfort. In this case, the patient has frequent, prolonged episodes of seizure clusters due to Dravet syndrome. The patient has responded poorly to repeated doses of intranasal midazolam and oral clonazepam and is at risk of life-threatening status epilepticus. In this clinical setting, given that current medical literature supports the use of the requested medication and as it has been recommended by the provider, the requested medication is medically indicated. Therefore, Valtoco (diazepam 5 mg nasal spray) 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. Findings: There is sufficient support for the requested medication in this clinical setting. Studies have shown Xifaxan to be highly effective for the eradication of bacteria and symptom relief for small intestinal bacterial overgrowth. Results are sustained for several weeks after treatment. The provider has recommended Xifaxan tablets, three times daily for 14 days, which is consistent with regimens used in these studies. In this case, there is documentation of symptoms and testing consistent with small intestinal bacterial overgrowth. Therefore, the requested Xifaxan 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the left breast. Contrast-enhanced breast MRI is a highly sensitive examination which has specific indications to help identify abnormalities that are occult on mammography and ultrasound. The indications for breast MRI include high-risk screening and when mammography or ultrasound findings are inconclusive. According to the American College of Radiology (ACR), MRI may be used for lesion characterization in the setting in which mammographic and sonographic findings are inconclusive and biopsy cannot be performed. This indication is applicable after additional diagnostic mammographic views and targeted ultrasound examinations have been performed. Contrast-enhanced breast MRI was indicated for this patient as it was unclear if the distortion was pathologic in etiology or secondary to prior biopsy. The MRI demonstrated no abnormal enhancement in the left breast and the provider concluded that the architectural distortion was post-surgical and benign. All told, the MRI of the left breast was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the MRI of the left breast was 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 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: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Overturned

The parent of a 10-year-old female enrollee has requested subtalar arthroereisis for treatment of the enrollees flat foot and tibialis tendinitis. Findings:  Two physician reviewers found that after careful review of the enclosed information and the literature on subtalar arthroereisis, the requested right subtalar arthroereisis would be more beneficial for this patient than other standard available treatment. Subtalar arthroereisis has been performed for over 40 years with a variety of implant designs and compositions. As reported by the American College of Foot and Ankle Surgeons in their current practice guidelines, advocates for the procedure state that subtalar arthroereisis is a minimally invasive procedure that does not distort the normal anatomy of the foot. The authors noted that there are numerous studies that demonstrate quite good efficacy. In addition, the procedure is reversible as the implant can be removed most often without difficulty. In this patients progress notes, the provider reports failure of conservative treatments including over the counter and custom orthotics, immobilization, and anti-inflammatory medication. At this time, further treatment options include aggressive and permanent surgical procedures including joint fusions, osteotomies, and tendon transfers. It should be noted that these procedures change the normal anatomy of the foot and may be irreversible. Consistent with the medical literature, the recommended subtalar arthroereisis is expected to provide an improved health outcome over standard therapies and should therefore be approved.