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

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage of digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue density was described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.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 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 parent of a 23-month-old male  has requested speech therapy for treatment of his speech delay and suspected autism.  Findings:  The physician reviewer found that on the Rossetti Infant-Toddler Language Scale performed in April 2011, the patient who was then 21-months-old had no speech and his expressive and receptive language abilities were at 9 months age equivalence. Although a diagnosis of autism has not yet been confirmed, the medical necessity of speech therapy hinges on whether the patients speech delay requires such intervention; the etiology of the speech delay is not determinative. The issue is whether the patient has a speech delay that can benefit from speech therapy.If a diagnosis of autism is ultimately confirmed in this case, there is robust medical literature advocating speech therapy for autistic children. The scientific literature strongly supports speech therapy for autistic children. The paper by Myers and Johnson is frequently cited in the autistic literature as a definitive source on the evaluation and treatment of autistic children. According to the authors, People with ASDs [autism spectrum disorders] have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. The paper by Turner is a controlled study comparing autistic children who did and did not receive speech therapy.  Those who did receive therapy had far greater communication skills than those who did not receive therapy. Further, 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.There is also wide support in the medical literature for speech therapy for children who are speech delayed, but not autistic. Law, et al. reports that children with speech delay can be readily treated. This finding is consistent with a review of multiple medical journal articles performed by Gorhus-Brower and colleagues, which specifically deals with speech-delayed children and points out that even intellectually delayed children are candidates for successful speech therapy. Prelock, et al. discusses the evaluation and therapy of speech delayed children and the successful utilization of speech therapy in this population.Regardless of the underlying diagnosis, this 23-month-old patient who is non-verbal is an appropriate candidate for speech therapy and such services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for food specific immunoglobulin G (IgG) allergy panel testing services.Findings: Three out of three physician reviewers found that food specific immunoglobulin G (IgG) allergy panel testing services are not likely to be more beneficial for the enrollee than any available standard therapy.Oral food challenges and oral food desensitizations have been performed successfully by allergists and immunologists. While oral food desensitization has been achieved in the majority of individuals in randomized controlled studies, few go on to develop tolerance or sustained unresponsiveness to the allergic stimulant. It is the standard of care to measure immunoglobulin E (IgE) levels to specific foods in question for a patient. However, an extensive array of blood tests examining foods to which a patient has not had a reaction to, in particular with immunoglobulin G4 (IgG4) testing, and proceeding with oral desensitization to a multitude of foods to which there is no history of anaphylaxis is not supported by the current medical evidence. In this case, the requested services are not evidence-based. Furthermore, while oral food challenges are medically appropriate to rule out IgE mediated food allergy, there is a lack of evidence in favor of oral dosing protocols for foods that are considered intolerances or IgE mediated allergies based on IgG and patch testing. Therefore, the requested Food Specific IgG Allergy Panel testing services are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in allergy and immunology. All reviewers 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 57-year-old male has requested an MRI for evaluation following an assault.  Findings:  The physician reviewer found that in this patients case, he has continued pain and headaches following the assault.  He had a normal CT scan of the head shortly following the episode of trauma.  Per the peer-reviewed medical literature, there is a lack of support for the use of additional imaging of the brain for patients with post-traumatic headaches who have no neurological or cognitive deficits.  When imaging of the brain is clinically indicated following trauma, CT scan of the head is the imaging of choice according to the American College of Radiology guidelines.  The current medical evidence does not support the requested MRI in this clinical setting.  In this patients case, his headaches are not associated with cognitive or neurological deficits, and no neurological deficits were noted on clinical examination.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that On readmission, the patient was not a danger to herself or others. She was medically stable. She was on lithium and Seroquel after stabilization on the inpatient unit, but still had auditory and visual hallucinations of being possessed by the devil.  Although records describe her as being able to distinguish what is real versus what is not, she stated that she would consider an exorcism.  A statement such as this does not reflect an individual who believes this is not a reality.  She appeared to be in a hypomanic state in that her speech was rapid and grandiose, and her behavior and affect were elevated.  It was not until later that perception and ideation were described as normal. However, her thought process remained circumstantial, she was hyperverbal, and her mood was elevated. The patient expressed low cravings, denied depression and anxiety, and expressed the desire to remain sober.  Given her long history of instability, psychotic ideation, impulsivity, substance abuse, and noncompliance with medication, although she was not a danger to self or others and was not gravely disabled, residential treatment was medically necessary for a few days.  However, the submitted records fail to demonstrate longer residential treatment. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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

The patient is a 44-year-old male who presented with left leg pain associated with varicose veins. The symptom severity is not documented; specifically there is no documentation that the symptoms interfere with activities of daily living.  There is mention of compression stocking use, but the length of time they were worn is not documented. A venous duplex exam is noted with no evidence of deep venous thrombosis, but the competency of the greater saphenous vein is not described. The patients provider has requested authorization for sclerotherapy to the left leg varicosities.  The Health Plan denied the request based on a determination that the procedure is not medically necessary.General practice guidelines in the specialty of vascular surgery dictate that symptomatic saphenous vein reflux and varicose veins warrant invasive treatment when the symptoms are severe enough to interfere with activities of daily living and are refractory to at least three months of conservative therapy with prescription compression stockings.  This patients symptom severity is not adequately documented, and there is insufficient documentation of an adequate (three month) trial of compression stockings.  The absence of proximal reflux in the greater saphenous vein is an additional generally accepted criterion for sclerotherapy.  The treatment of branch varicosities with sclerotherapy in the presence of saphenous reflux is associated with a high rate of recurrence and unproven efficacy.  No venous duplex results are submitted to document the lack of saphenous reflux.Isolated sclerotherapy of branch varicosities in the absence of saphenous reflux may be medically appropriate if the patients symptom severity, conservative therapy, and lack of saphenous reflux were appropriately documented. Based on the documentation submitted for review, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested GeneSight testing for medical evaluation of her bipolar disorder and post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that  the American Psychiatric Association (APA) practice guidelines do not recommend genetic testing for cases involving routine medication management. Regarding this patients scenario, there is a lack of specific information detailing the history of her illness, functional impairment, or contemporaneous psychosocial stressors. Further, there is no documentation of prior treatment interventions tried and failed, including the type, setting and outcome. In the absence of this information, the requested GeneSight testing is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee requested speech therapy for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the medical literature supports speech therapy in this clinical setting.  The patient is a 13-year-old autistic male who utilizes DynaVox to communicate. The records show that he continues to learn to use the DynaVox device with reported progress in communication goals. Although, his progress has been noted as slow, he is reported to have demonstrated consistent skills in basic communication, receptive and expressive language and social language. As such, continued speech therapy is medically necessary in this clinical setting for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a Dexcom G6 Sensor. Continuous glucose monitoring system (CGMS) is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. As noted in the medical literature, CGMS can help identify fluctuations, maintain tight glycemic control, and prevent hyper and hypoglycemia. Use of CGMS can reveal high blood sugar levels between meals and show early morning spikes in blood sugar. CGMS has been shown to improve the hemoglobin A1C levels of diabetic patients. For this patient, CGMS has provided useful data for reducing glycemic variability and adjusting his insulin pump settings. For these reasons, CGMS devices have been confirmed to have high accuracy in glycemic values with a low complication rate. Given this support, the Dexcom G6 Sensor is medically necessary for treatment of this patients type 1 diabetes.Final Result: The reviewer determined that the requested device 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the spine.The submitted documentation supports the medical necessity of the requested services in this clinical setting. Many studies have reported a high incidence of osteoporosis in patients with Ehlers-Danlos syndrome. Studies reported the prevalence of vertebral fractures in Ehlers-Danlos syndrome patients with chronic back pain. Vertebral fractures were significantly more prevalent in Ehlers-Danlos syndrome patients as compared to normal controls. Severe back pain was more frequent in these patients for that reason. In light of this study, the patients request for an MRI scan of the spine in order to accurately diagnose the cause of her low back pain is medically appropriate. Therefore, the requested MRI of the spine is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old female enrollee has requested for Avastin for treatment of her stage IV non-small cell lung cancer.  Findings:  Two physician reviewers found that Avastin has been demonstrated to have some usefulness when combined with initial chemotherapy with carboplatinum-taxol in metastatic non-small cell lung carcinoma and it is approved for such use. However, there is no data that Avastin combined with other agents later in the course of treatment of non-small cell lung carcinoma has been clearly beneficial.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested for Lap-band removal and either gastric bypass or sleeve revision for treatment of the enrollee's post Lap-band placement. Findings:  The physician reviewer found that this patient has developed recurrent and persistent nausea and vomiting.  In this clinical setting, further deflation of the band should be part of the evaluation for ongoing nausea and emesis. Therefore, it is anticipated that further deflation may reduce the restrictive nature and ameliorate the nausea, although it is not likely to facilitate further weight loss..  In this clinical setting, band deflation and evaluation for complications are medically indicated prior to band removal and either gastric bypass or sleeve revision.  All told, the requested Lap-band removal and either gastric bypass or sleeve revision are not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested a one-year follow-up evaluation by his eye surgeon for treatment of his status post eye surgery. Findings:  The physician reviewer found that the patient had a Baerveldt glaucoma valve implant, and there were complications. The complications were very well handled by the surgery done. The patient has done very well postoperatively in regards to his uncontrolled glaucoma. The patient is now under the care of the in-network retinal specialist. This physician has treated the patients diabetic retinopathy in the past. The patient is very stable at present and has no acute problems.  On the said date the patients intraocular pressure was well-controlled and his vision was maintained with the treatments done by by the specialist.  A referral is not medically necessary at the present time. The patients clinical retinal problems can be treated by the in-network retinal specialist.  All told, a one-year follow-up evaluation by the patients eye surgeon is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) scan of the brain (cerebral perfusion imaging using CT) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the CT scan of the brain (cerebral perfusion imaging using CT) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this clinical setting, the CT perfusion was indicated to rule out acute stroke, given that this patient has multiple risks factors for strokes. In sum, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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 reviewer number one is board certified in neurology with sub-specialty certification in neuro-oncology and is actively practicing. Physician reviewer number two is board certified in radiology with sub-specialty certification in neuro-radiology and is actively practicing. Physician reviewer number three is board certified in medical oncology and is 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

The patient is a 32-year-old female with a history of rib fractures following a bicycle accident in December 2005. X-rays obtained in March 2006 showed healed posterior right rib fractures. The findings of a nuclear bone scan were consistent with healing fractures. The patient continues to have pain and has requested authorization for a CT scan for further evaluation. The Health Plan has denied her request citing a lack of medical necessity for a CT scan in this setting.The Health Plans denial is correct.  The patient has rib fractures that appear to be healing based on the plain radiographs. The results of a nuclear scan also showed healing. A CT scan is not clinically indicated for this injury. The patient does not require surgery. No added benefit would be obtained from a CT scan and therefore, the proposed scan is not medically warranted. Accordingly, I have determined that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested back surgery for treatment of his radicular back pain.  Findings:  The physician reviewer found this patient presents with chronic low back pain. The records indicate that his pain generator has not been identified, he has no evidence of a disc herniation, and has does not have a defined lumbar radiculopathy. He has had some minimal conservative measures but has not exhausted conservative care. Given the lack of documentation that the patient has exhausted conservative treatment and does not have any indication for surgery, the requested surgical intervention is not appropriate (Gibson, et al; Chou, et al). Therefore, the proposed surgery is not medically necessary for treatment of this patients medical condition.