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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive home-based feeding therapy.Feeding problems are a common childhood complaint, and in some children may be severe enough to result in growth failure and susceptibility to illness. Feeding problems are particularly common in patients who are developmentally delayed. Patients with autism frequently have oral aversions due to taste, texture, and presentation. While these children are not typically failing to thrive, the restricted diet can lead to nutritional deficiencies, which in some cases can be quite severe. Patients may acquire micronutrient deficiencies as well as macronutrient deficiencies. Some patients may limit liquid, leading to dehydration. In this patients case, the records document severe oral aversion and restricted eating. He is likely malnourished because of the restrictive nature of his diet. In addition, he will only take one type of liquid which is no longer being manufactured. Fluid restriction will lead to severe dehydration unless it is aggressively addressed. The patient has participated in two feeding programs, and both failed to resolve his feeding difficulties. He now requires an intensive feeding program. An in-home program is necessary because it incorporates all aspects of the patients environment. Therefore, the requested intensive home-based feeding therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics 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 the DecisionDx-Melanoma Gene Assay testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay 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 DecisionDx-Melanoma Gene Assay 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 DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in dermatology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition. The Health Plan has denied digital breast tomosynthesis as investigational/experimental for evaluation of the patient. Findings: Three physician reviewers found that the patient had a digital breast tomosynthesis performed as part of her routine screening mammography.  The patient's status is post lumpectomy of the right breast along with radiation and chemotherapy in 2006. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The digital breast tomosynthesis was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening.Final Result: Three 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 overturned.Credentials/Qualifications: All three physician reviewers are 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 26-year-old female enrollee has requested acute inpatient services for treatment of her substance use disorder. Findings:  The physician reviewer found that this patient was admitted to an inpatient program that was predetermined in length with a rather uncomplicated detoxification protocol. This type of detoxification plan can usually be safely and effectively provided on an outpatient level of care. There were no acute medical or psychiatric problems that would be expected to complicate the course of treatment and she presented no major obstacles to her care. The fact that she tried to detoxify herself at home and failed is not a criterion for medical necessity. As such, the patient could have safely and effectively been managed in a less restrictive treatment setting with medication management, and the acute inpatient services were not medically necessary for treatment of her condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that documentation has been provided which demonstrates that this patient failed multiple abortive and preventive headache therapies. Additionally, the documentation indicates the patient had a previous positive response to Botox therapy. This new data supports the continued use of Botox to help manage this patients headaches. In this particular case, given the patients failure to respond to multiple standard headache therapies, the use of Botox is likely to be more beneficial for treatment of the patients headaches than continued attempts with standard therapies.
Appeal type: Urgent Care
Decision: Upheld

A 44-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient had back pain with sciatica that had been present for three to four weeks by the time he presented to the emergency department. This chronology suggests that the patients symptoms were not acute in nature. While a patient could reasonably seek emergent treatment for pain, this patient only rated his pain a 1 of 10 (on a 10-point scale). Moreover, the patient did not report his cardiac symptoms to the provider upon evaluation, and there were no worrisome symptoms or findings noted in the patients chart. All told, a prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for therapy sessions for treatment to develop a relationship with a family member.Findings:  The physician reviewer found that the patient has requested therapy sessions in order to develop a relationship with a family member. The patient had a telephone intake, and the clinician who completed the intake opined that the patient was not in need of behavioral health services due to a lack of clinical findings or clinical diagnosis. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a mental disorder is defined as a syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, for developmental process underlying mental functioning.   Mental disorders are usually associated with significant distress or disability in social, occupational, for other important activities. According to the material and clinical information presented for this review, the records do not demonstrate a mental disorder.  Psychotherapy involves treatment planning as well as treatment goals that would typically include symptom reduction of some type.  In this case, there is no indication of a symptom that would be the target of a treatment goal. It appears that the patient would like to develop a relationship with a family member, but there is no clinical indication to support any targeted treatment goals.  Final Result: The reviewer determined that the requested treatment was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The Physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued inpatient psychiatric hospitalization (IP) treatment from 8/22/16 through 8/31/16. Findings:  The physician reviewer found that on 8/22/16, the patients psychosis had improved.  She was stable on antipsychotic medication. She was calm, cooperative and pleasant. She was neither agitated nor intrusive. She was not suicidal. She was sleeping nearly eight hours per night.  She was anxious about discharge, and still demonstrated findings consistent with a formal thought disorder. However, the psychiatrist considered her appropriate for discharge back to a less restrictive setting. A critical element to a successful inpatient psychiatric hospitalization is appropriate aftercare.  Although a return to a prior residence is often ideal, suitable alternatives may be clinically appropriate.  In this case, the record indicates that the illness burden which had prompted the hospitalization had improved significantly.  Although disabled by chronic mental illness and in need of a supervised setting, there was no evidence of an acute psychiatric syndrome or medical crisis as of 8/22/16.  Thus, a less restrictive treatment setting, such as a sub-acute crisis bed or short-term residential unit, would have been clinically appropriate. 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: Overturned

The patient is a 16-year-old male (almost 17-years old) with a weight of 508 pounds and a body mass index (BMI) of 79.6. His comorbid conditions include asthma, dyspnea on exertion, depression, obstructive sleep apnea and stress incontinence. The patient has completed a psychological evaluation and it was determined that with supportive therapy, he is an appropriate candidate for weight loss surgery. The Health Plan has denied the parents request for coverage of bariatric surgery based upon their determination that the procedure is not medically necessary.With a BMI of 79.6 and comorbid conditions such as asthma, dyspnea on exertion, depression, obstructive sleep apnea and stress incontinence, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for him. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. The psychological evaluation indicates the patient is a viable candidate for the surgery with appropriate follow up.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
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 unspecified emotional disturbance and concurrent difficulties with sensory integration. Findings:  The physician reviewer found that speech and language therapy with emphasis on pragmatic language and social skills is medically necessary for this patient based on the submitted clinical information. Social communication is essential for development of peer relationships, as well as performance at home, school, and in the workplace. Children with social communication problems have difficulty with interpersonal communication and oral and written communication. Using language in an effective and appropriate manner in social situations requires pragmatic language competency. Increasingly, deficits in this area are linked to child and adolescent disorders. Because of the implications of continued deficits in this area, early intervention is essential. This patient has deficits in pragmatic language. He has difficulties with executive control functions and sensory integration as well. Whether these challenges are due to right hemisphere dysfunction or autism spectrum disorder (as indicated on the ADOS), they represent some type of neurological deficit. Historical and continued speech and language therapy with emphasis on social skills and pragmatic language development is therefore medically indicated and appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 blood test provided for evaluation of the enrollees gastric adenocarcinoma. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Guardant360 testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Guardant360, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of Guardant360 in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Guardant360 test provided 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 testing at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a Breg Vista multi-post cervical collar. There is a paucity of evidence in current medical literature to support the use of cervical collars in general in the treatment of neck pain. When considering recommendations for the management of spinal disorders including neck pain, Chou and colleagues concluded, Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction. In a clinical practice guideline for physical therapists addressing the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, Bier and colleagues specify, The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar. In a systematic review of the effectiveness of conservative treatment for patients with cervical radiculopathy, Thoomes and colleagues found, There is low-level evidence that a collar is no more effective than physiotherapy at short-term follow-up and very low-level evidence that a collar is no more effective than traction. The authors further concluded, On the basis of low-level to very low-level evidence, no one intervention seems to be superior or consistently more effective than other interventions. In this case, the patient is undergoing treatment for cervical radiculopathy. Notes reported that the patient is experiencing neck and arm pain. While the provider has recommended the use of a cervical collar, given the lack of evidence in current medical literature supporting the use of cervical collars in the management of chronic neck pain, the requested equipment is not medically indicated. Therefore, a Breg Vista multi-post cervical collar is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested stereotactic body radiotherapy (SBRT) as part of the Trilogy protocol for the treatment of her pancreatic cancer. Findings:  Two physician reviewers found that the patient has unresectable, locally advanced, pancreatic cancer. A protocol involving chemotherapy followed by SBRT single-fraction treatment and then further chemotherapy was recommended. The previous SBRT studies for pancreatic cancer have shown improved local control but there was no improvement in overall survival. There is no phase III randomized trial yet. Until the results of the current protocol study are available, it cannot be concluded that the disputed procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.