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 400 hours of private duty nursing in the home setting. Children with special needs frequently require equipment at home to allow for safe and effective care. Such equipment may facilitate feeding and eating, toileting, bathing, safe sleeping, and mobility, as well as offer opportunities to achieve functional skills. This patient has a number of skilled nursing needs and requires constant supervision, monitoring, and skilled intervention should he develop respiratory distress, signs and symptoms of aspiration, or seizures. This is not something that can be safely managed by layperson caregivers, such as parents, around the clock. Thus, the requested 400 hours of private duty nursing in the home setting 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 with sub-specialty certification in pediatric critical care medicine 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 authorization and coverage for stereotactic body radiotherapy.  Findings:  The physician reviewer found that the patient has a recurrence of ovarian cancer following standard chemotherapy.  Standard treatment in this setting is with second-line chemotherapy.  There are cases when patients with certain histologies with limited metastatic disease are eligible for SBRT.  However, an oligometastatic state for ovarian cancer has not been described in the medical literature.  There is a lack of convincing medical evidence which suggests that patients with ovarian cancer benefit from SBRT. The primary pattern of failure for patients with ovarian cancer is systemic, which is why treatment is with chemotherapy.  Thus, SBRT is not likely to be of greater benefit than other methods of treating this patient.  Final Result: The reviewers 2 of 3 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: Physician reviewers 1, 2 & 3 are board certified in radiation 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Bystolic 5 mg daily. While beta blockers are not regarded as the optimal first-line therapy for the management of hypertension, they may be indicated in certain clinical situation, especially in conjunction with an angiotensin II receptor blocker (ARB) as in this case, including for patients with rhythm disturbances, angina and prior myocardial infarction. In this case, the patient has a history of frequent premature ventricular contractions (PVC). Medical literature notes that potential PVC triggers include uncontrolled hypertension, and that the most common treatment medical therapy for patients with significant or persistent PVC related symptoms includes beta blockers. The patient has reported side effects with other trialed beta blockers, including other B-1 selective medications, and good response to Bystolic over a prolonged period. In this clinical setting, given the patients history of frequent PVC and as the records reflect that he is also on an ARB, the requested medication is indicated for the treatment of hypertension. Therefore, Bystolic 5 mg daily 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 cardiovascular 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Harvoni tablets for eight weeks. Findings: Guideline recommendations for the treatment of hepatitis C state, From a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus (HCV) eradication. Therefore, the panel continues to recommend treatment for all patients with chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy.` Given that it is standard accepted therapy for the treatment of hepatitis C, the requested medication is medically indicated. Therefore, Harvoni tablets for eight weeks 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 infectious 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for the psychiatric residential treatment center for treatment of her behavioral health issues.  Findings:  The physician reviewer found that initial psychiatric evaluation showed no evidence that there was an emergency mental health problem that would justify admission to a psychiatric residential treatment center. Psychotropic medication was not started until more than two months after admission. The patients social history and psychiatric evaluation revealed that a major factor in patients depression, suicidal behavior, feelings of abandonment, and loneliness were likely indications of reactive attachment disorder (RAD), which was one of the diagnoses initially considered. The diagnosis of reactive attachment disorder had been considered in the patients previous treatment and in the patients discharge summary. The American Psychiatric Publishing Textbook of Psychiatry states that RAD is best treated with dialectical behavior therapy that involves both the adolescent and the parent. The patients discharge treatment plan recommended essentially the kinds of outpatient treatment that would have been appropriate prior to the patients admission to the RTC. The services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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:   The parent of an enrollee has requested Anser IFX testing for evaluation of the enrollees Crohns disease.  Findings:  Three physician reviewers found that recent studies indicate that drug level monitoring is being used with increasing frequency to predict durability of response and to guide decision making in those not responding adequately. Literature published over the past several years increasingly points to benefits of therapeutic drug level monitoring as preventing unnecessary exposure to a drug in a futile exercise, and helping to make timely decisions regarding switching medications within the same class or to another class. Several algorithms have been proposed and a common sense approach to their use has been widely adopted. At this point, they are used routinely in centers catering to large populations of inflammatory bowel disease (IBD) patients primarily in an attempt to maximize and prolong the benefit of a very useful drug category.  One groups 10-year experience identified loss of response to infliximab in line with other studies at 12% after year one and pointed to the likely relationship to development of antibodies to infliximab (ATI). Empiric dose adjustment no longer seems reasonable in a time when data is available for guiding those decisions. This is especially true in the pediatric population where timely decision making regarding choice of drug is critical to preserving growth and decreasing the likelihood of surgery. In this case, the patient had already been through several dose adjustments and the result of the Anser IFX testing in this circumstance likely provided clinical benefit that would not otherwise have been ascertained.  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 reviewers are board certified in pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested Avastin and Abraxane combination therapy for treatment of her metastatic melanoma.   Findings:  Two physician reviewers found that metastatic melanoma is a disease with an extremely poor prognosis, for which there is no effective standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines suggest a clinical trial as the favored option for the treatment of this disease. Unfortunately, there are few clinical trials available, and most patients must be treated with currently available agents. Of the available agents, a reasonable amount of success has been reported using paclitaxel, nab-paclitaxel (Abraxane), and bevacizumab (Avastin). Several phase II studies have been reported using these agents, with results superior to what would be expected with historically available agents.  As such, given the lack of effective therapies in this setting, as well as the promising results associated with the combination of Abraxane and Avastin to date, the proposed regimen likely offers this patient the best chance of therapeutic benefit.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old male with a history of severe chronic pain of the low back, shoulders, neck, and joints after a near fatal accident. The patient also states that he has been HIV positive for 14 years and hepatitis C positive for 5 years. The patient has been tried on numerous narcotic medications including Percocet, Percodan, Norco, Duragesic patch, OxyContin, MS Contin, morphine sulfate, and Actiq. The patients most recent medication regimen appears to have been Percocet 2 tablets every four hours and Duragesic patch 100mcg per hour in addition to Actiq, which was prescribed in June 2004. It appears the patient is also taking Valium and Restoril.The patient states that the only narcotic that has provided pain relief is Actiq. The Health Plan has denied authorization for Actiq on the basis that it is not medically necessary for treatment of the patients medical condition.This patient with severe musculoskeletal pain involving his low back, shoulder, and neck, is seeking additional narcotic medication (Actiq) after indicating that his current regimen of Duragesic patch and Percocet does not control his pain. The patient seems to be requiring increasing doses of narcotics in treating his chronic, severe, non-cancer pain. Actiq is currently indicated for severe breakthrough cancer pain. Actiq has potentially serious side effects; its use in this clinical context in the absence of breakthrough cancer pain is not medically warranted. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male has requested  coverage for speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that as noted in the medical literature, Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success (Sharp, et al). Further, patients with speech and language delays may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. In addition to persistent speech and language related underachievement, language-delayed children have also shown more behavior problems and impaired psychosocial adjustment. From this detailed account, it is clear that speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial. According to Pennington and colleagues meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors commented that, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. With regard to treatment, the reviewers concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient presents with a severe expressive language delay that is negatively impacting his ability to communicate in a functional and age-appropriate manner. Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Experimental/Investigational
Decision: Overturned

59-year-old female enrollee has requested a contrast-enhanced computed tomography of the chest for evaluation of the her chest pain.  Findings:  Three physician reviewers found that while it appears a coronary CT angiography was initially ordered by the provider, review of the procedure report from said date reveals no mention of the coronary arteries in the report or of the CT scan having been performed as a coronary CT angiography. The procedure actually performed was a CT scan of the chest, which is a routine diagnostic procedure that is not considered experimental or investigational for the evaluation of chest pain. There is ample data to support the role of CT scan of the chest in the evaluation and treatment of patients with chest pain, as was the case with this patient. As such, the Health Plans denial of this service should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested an abdominoplasty in conjunction with repair of incisional hernia for treatment of her excess skin.  Findings:  The physician reviewer found that the patients condition constitutes an abnormal structure of the body. Panniculectomy is a lesser procedure than abdominoplasty in that it only involves removal of the lower abdominal skin without muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty. It is medically necessary rather than cosmetic in nature when the removed skin has a history of recurrent infections, as in this patients case. The records provided for review demonstrate that this patient has been treated on numerous occasions for skin rash and irritation with topical creams and persistence of the condition despite treatment. Thus, the requested surgery is primarily being performed to stop recurrent skin infections and thereby improve the patients function. As such, even though the proposed surgery will improve appearance, this is not the primary purpose of the procedure and it is therefore medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 19-year-old male enrollee has requested for services for treatment of his second and third degree burns. Findings:  The physician reviewer found that there is nothing in the record that demonstrates that the patient is not stable for transfer. Nor is there any evidence that the services available at the in-network burn center are inadequate to treat the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested cryotherapy for treatment of the enrollees acne vulgaris and verucca vulgaris. Findings:  The physician reviewer found that Cryotherapy induces superficial peeling due to epidermal necrosis, which causes desquamation of comedones, resolution of inflammatory papules, pustules, nodules and cysts. Ultraviolet therapy and cryotherapy/cryoslush therapy can be used in combination to treat acne when other methods have failed and/or caused untoward side effects. The use of cryotherapy for treatment of warts is the standard of care and consistent with generally accepted dermatologic practice. Additionally, the use of cryotherapy for the treatment of acne vulgaris is medically appropriate and indicated for patients such as this patient who have tried and failed multiple other treatment methods.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old female enrollee has requested for the auditory processing skills evaluation for evaluation of the enrollees pervasive developmental disorder not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that the available peer reviewed medical literature demonstrates that there is no evidence that auditory processing therapy or other sound therapies are effective as treatments for autism (Sinha, et al., 2011; and Sinha, et al., 2006). The 2011 Cochrane review published by Sinha and colleagues found that six randomized controlled trials of auditory processing therapy (also referred to as auditory integration therapy) were identified with a total of 171 individuals aged 3-39 years. Four trials had fewer than 20 participants. The authors reported that meta-analysis was not possible due to very high heterogeneity or presentation of data in unusable forms. They further noted that three studies did not demonstrate benefit of auditory integration therapy over control conditions and that the improvements reported in the remaining trials were of questionable validity. The authors concluded that more research is needed to inform clinical decision making about auditory integration therapy for individuals with autism spectrum disorders. Given the lack of data supporting the use of auditory integration therapy in this setting, the disputed auditory processing skills evaluation was not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast augmentation. Bilateral breast augmentation is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) acknowledged that medically necessary gender confirming surgical interventions might include chest reconstruction or augmentation as appropriate for each patient, including nipple resizing or placement of breast prostheses. WPATH noted that for some patients, relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity. Clinical notes from this patients multidisciplinary transgender care team support a diagnosis of gender dysphoria. The records suggest that the patients distress related to her gender dysphoria would be greatly improved with a bilateral breast augmentation. All told, the requested bilateral breast augmentation is medically necessary for 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 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

A 50-year-old male enrollee has requested for lymphoscintography and sentinel node biopsy performed by a surgical oncologist rather than a plastic surgeon for treatment his melanoma. Findings:  The physician reviewer found that given the importance of correctly identifying lymph drainage areas from the anterior abdomen and the importance of correctly identifying and evaluating lymph nodes in situ and correctly removing for analysis such sentinel nodes, the requested services are medically indicated and necessary.