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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for speech therapy services and future services for treatment of the mixed receptive-expressive language disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the services at issue. The US Preventive Services Task Force support speech therapy services for children with speech language delays.  The meta-analysis performed by researchers found that longer duration of speech therapy was associated with improvements, and evidence of improvements in expressive language with speech therapy.  Per the results from Rossetti Infant-Toddler Language Scale testing, the patient has considerable speech delay with skills at the nine to 12 month age level at the age of 21 months. In addition, the patient is now 27 months and only utilizes five words. All told, speech therapy is clinically indicated for treatment of the patients moderate speech language delay.  Final Result: The reviewer determined that the services at issue were and 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 developmental and behavioral 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: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested an additional one hour of speech therapy per week (two hours of speech therapy per week for medical treatment of the enrollees expressive language disorder and autism spectrum disorder.  Findings:  The physician reviewer found that the patients evaluation showed that his language skills were severely delayed. ABA services address communication goals, specifically pragmatic language goals. Speech/language therapy addresses expressive and receptive language goals. Reichow and colleagues showed that early intensive intervention provides the best outcome for children with autism spectrum disorder. The patients speech progress report shows he is making progress, but he is still behind his peers. For the reasons provided, it is medically necessary for this patient to have an additional one hour of speech therapy per week (two hours of speech therapy per week).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a whole house generator.  Findings:  The physician reviewer found that the physician reviewer found the patient is technology dependent for survival. He requires mechanical ventilation, supplemental oxygen, suction, and continuous feedings via pump. Without these interventions, he would not be able to be cared for in the home. With power interruption, his technology is available only as long as battery power provides functionality. In the case of prolonged outage, as may occur with poor weather conditions, downed power lines, or prolonged repair/expansion, he must be taken to the emergency department for management. This is not a viable option for this family with a single caregiver. The current standard is to facilitate disaster and emergency preparedness amongst families of technology dependent children to prevent unnecessary morbidity and increased potential for mortality. A whole house generator system properly designed and operated is thus medically indicated. All told, the requested whole house generator is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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

A 60-year-old male enrollee has requested minimally invasive lumbar decompression (MILD) for treatment of his low back pain.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective than other available treatment options.  There is a lack of support for the requested services in this clinical setting.  The current medical literature has not demonstrated the superior efficacy of the MILD procedure in this patients case.  There is a lack of evidence indicating that this procedure would be more beneficial than the standard approach.  Therefore, minimally invasive lumbar decompression is not likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 21-year-old male enrollee has requested residential treatment for treatment of the enrollees major depressive disorder, recurrent, severe, with psychotic features, generalized anxiety disorder, adult attention deficit/hyperactivity disorder, panic attacks, opiate dependence and polysubstance abuse. Findings:  The physician reviewer found that the medical documentation indicates a significant history of opiate dependence. This patients history is positive for multiple relapses with outpatient services.  He presented for treatment with withdrawal symptoms consisting of night sweats, irritability, cravings, panic attacks, nervousness, muscle cramps, depression and sleep disturbance. He was placed on a detox protocol.  He also described suicidal urges and reported previous overdose attempts. A psychiatric assessment established the diagnoses of major depression, severe, with psychotic features, opiate dependence and polysubstance abuse. His judgment and insight were poor. The patient continued to display significant anxiety during the course of treatment and was fearful as discharge planning progressed.  Given the severity of the patients substance dependence, severe functional impairment and comorbid major depression with suicidal urges, intense treatment in a residential setting is medically indicated. Residential treatment is indicated per American Psychiatric Association Practice guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement of Decision Dx-Melanoma Gene Assay. Findings:  Three physician reviewers found that the enrollee underwent shave biopsy of the right buttock and the dermatopathology report showed invasive malignant melanoma; arising with dermal nevus, Clarks level II, Breslow depth of invasion 0.20 MM. She then underwent a wide excision of the lesion. The Decision Dx-Melanoma Gene Assay was ordered for the prediction of metastatic recurrence. The result was Class 1, Sub-Class 1A which is associated with a low risk of recurrence within five years. She continues with office visits for skin cancer surveillance. Per the medical literature, diagnostic molecular techniques are still largely investigative and are not recommended for routine diagnostic use in cutaneous melanoma. The Decision Dx-Melanoma Gene Assay has not been validated against prognostic factors that could be used to determine prognosis. The data is based on a small sample size. The sample size would need to be larger to reduce the risk of false positives and to advise an enrollee previously thought of as low risk to proceed with invasive procedures based on the results of the testing. DecisionDx-Melanoma Gene Assay is not currently recommended by any standard treatment guidelines. Assessment of the sensitivity and specificity of this test in prospective enrollees, along with guidance on results interpretation, is of critical importance. Clinicians may suggest more frequent clinical evaluations and surveillance imaging for enrollees predicted by this test to be at high risk for metastasis; however, in settings in which adjuvant therapies are either contraindicated or not available, this categorization may increase enrollee anxiety without real benefit to the enrollee.Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology 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

The patient is a 47-year-old female with a history of whiplash from a bus accident in August 2004. She received 12 physical therapy visits. She had some improvement with therapy and is requesting additional physical therapy visits for her pain. Records indicate she has chronic cervicalgia. The physicians notes are not comprehensive. As of November 2004, the patients headache had resolved and her depression was stable in December 2004. The patient continued with therapies but records provide little evidence of progressive improvement. The symptoms continued with little change through January 2005.As of January 2005, the therapy at issue did not produce improved subjective or objective complaints. In addition, on-going exam findings have remained the same. Based upon a lack of improvement in the patients condition and no indications for on-going therapy in the records, it is evident therapy after January 2005 was not medically necessary. Therefore, I have determined that the requested therapy 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 a lower back epidural injection for medical treatment of her low back pain syndrome.  Findings:  The physician reviewer found that there is a lack of documentation demonstrating that the patient has failed conservative therapy including physical therapy and weight loss management.  Given the patients lack of conservative therapy, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested a tonsillectomy for treatment of her tonsil hypertrophy.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested procedure. Although the patient reported three episodes of sore throats each year for three years, there is no medical documentation that the patient had been evaluated for those acute episodes, and there is no documentation suggesting that the patient had received appropriate medical therapy including antibiotics for those episodes. According to the Clinical Practice Guideline by the American Academy of Otolaryngology-Head and Neck Surgery, the clinical criteria for consideration of surgery in patients with symptoms of recurrent acute tonsillitis suggest that patients with episodes of these infections of three or more times per year for more than three years in a row may meet criteria for that surgical intervention. Although the patient states that she has had that many episodes, these are not documented in the medical records provided. Additionally, there is no documentation of active symptoms of sleep disordered breathing in the records provided or any evidence that the patient has undergone polysomnography to evaluate sleep disordered breathing. In this circumstance, the patient does not meet medical necessity criteria for surgical intervention. All told, the medical necessity of the requested service has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret three tablets daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic Hepatitis C genotype 1 regardless of fibrosis stage (Kwo, et al; Zeuzem, et al). The ENDURANCE-1 trial showed that only 8 weeks of treatment is needed (Zeuzem, et al). The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). 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 bronchial thermoplasty for treatment of the enrollee who has a history of uncontrolled asthma. Findings:  The physician reviewers found that The Food and Drug Administration (FDA) has approved bronchial thermoplasty for the treatment of adults 18 years or older who are diagnosed with severe asthma that is not well controlled with inhaled glucocorticoids and long acting beta agonists. Bronchial thermoplasty refers to a technique of applying heat to the airways during bronchoscopy and reduces the increased mass of airway smooth muscle associated with asthma. The medical studies have shown a significant improvement in patients who underwent bronchial thermoplasty. In a follow up of 162 patients who underwent bronchial thermoplasty in the AIR2 trial, the proportions of subjects experiencing exacerbations or emergency department visits in years one to five were lower by 44 and 78 percent, respectively, compared with the year before bronchial thermoplasty. Based on the submitted clinical information supported by progress notes and pulmonary function testing, this patient met the criteria for coverage for bronchial thermoplasty.  The clinical information shows evidence such as the need for intermittent/continuous oral glucocorticoids and maximal inhaled corticosteroid treatment. Therefore, bronchial thermoplasty was likely to have been more beneficial for the treatment of this patients medical condition than the available standard methods. Final Result: Two of three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in allergy and immunology and 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 42-year-old female enrollee has requested physical therapy incorporating eccentric strengthening exercises for treatment of her Achilles tendonitis. Findings:  The physician reviewer found that achilles tendinopathy is essentially a degenerative condition related to overuse.  It can be a difficult condition to treat. At present, treatment recommendations generally revolve around relative rest (e.g., using heel lifts to reduce tendinous excursion), stretching, strengthening exercises, and passive modalities for palliation and improved tolerance for exercise.  Eccentric load training is generally considered to be an appropriate measure for relieving symptoms and improving outcomes.  In this case, the patient has undergone extensive physical therapy, including training in eccentric exercises. She has been receiving passive modalities and been performing basic general and lower limb exercises that she could have been performing independently. There is no proven benefit of prolonged supervised physical therapy consisting of formal modalities, manual therapy and supervised exercises for the patient's condition. The patient should have been performing eccentric loading exercises on her own after a very short course of training with physical therapy.  All told, the requested physical therapy incorporating eccentric strengthening exercises is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for Axumin positron emission tomography (PET) scan. The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees who has a history of prostate cancer.Findings:  Fluciclovine, the compound used for PET imaging in the Axumin scan has been approved by the U.S. Food and Drug Administration and included in the National Comprehensive Cancer Network (NCCN) guidelines as a procedure of choice for the evaluation of men with rising PSA following prostatectomy.  The medical literature indicates this agent has proven to be very sensitive in the detection of residual tumor in the prostate bed, lymph nodes and even bones in such patients.  The detection of recurrence allows for targeting the recurrence for therapy and is the best chance for prolonging survival and cure. In this patients case, his steadily rising PSA from an undetectable level to the current level is of concern for recurrence particularly in light of the positive surgical margins.  This patient does not have symptoms of recurrence but rather has a well recognized biomarker causing suspicion of recurrence.  For these reasons, the Axumin PET scan for evaluation of this patients medical condition is likely to be more effective than the available treatment options.  Final Result: Two of the three reviewers have determined requested services are 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 diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (nuclear magnetic resonance (NMR) lipid panel screening). Findings:  Three physician reviewers found that in this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density-lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin-resistance, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Final Result: Three 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 cardiovascular disease 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that tomosynthesis has proven to be a very useful screening tool to screen for breast cancer. However, once an abnormality has been found and the work-up of mammography and ultrasound follows, the addition of tomosynthesis does not add appreciable value. The spot magnification views and the ultrasound will provide enough information for recommendation and management. Thus, the addition of tomosynthesis did not add to the conventional views. Therefore, the use of breast tomosynthesis was not 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 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 reviewers are board certified in diagnostic radiology 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.