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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that the breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the efficacy of tomosynthesis for this patients routine breast cancer screening.  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. 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

A 38-year-old male enrollee requested authorization and coverage of ABX-EGF and/or GW572016 along with 5FU/LV and CPT for the treatment of colon cancer.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that ABX-EGF and/or GW572016 along with 5FU/LV and CPT  is not likely to be more beneficial for treatment of the enrollees colon cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100-40 mg three tablets daily for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. 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 should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 6 patients should be treated with Mavyret, three tablets daily for eight weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg three tablets daily for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned

A request for two hours per week of speech therapy services was submitted by the enrollees parent. The Health Plan denied the request as not medically necessary.Autism spectrum disorder is a neurodevelopmental disorder defined by deficits in social communication and the presence of restricted and repetitive behaviors and interests. Treatment involves intensive behavioral therapy and educational programming along with speech and language, occupational, and physical therapies. Psychopharmacologic treatments are also used to target certain symptoms and comorbid conditions. Colleagues concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal patients with developmental disabilities. A recent study published by colleagues described that systematic instruction teaching multistep social-communication skills to children with autism spectrum disorder using an iPad is effective in developing advanced social-communication skills. In this case, the patient has made slow progress with speech therapy. His scores on the Receptive and Expressive One Word Picture Vocabulary Tests indicate that he has not reached a plateau and is making gradual progress. As such, the continuation of speech therapy services for one hour per week is medically necessary. The additional hour of speech therapy services per week is not medically necessary.Final Result: The reviewer determined that some of the requested services are 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 pediatrics and neurology with special qualification in child neurology, 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 reimbursement and prospective authorization and coverage for residential substance use disorder treatment level of care. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patients COWS scoring from 10/29/19 showed mild to moderate withdrawal. The patient meets the criterion for dimension 2, as he has insulin dependent diabetes mellitus requiring continuous monitoring. The records support dimension 3 as the patient has comorbid schizophrenia and PTSD. For dimension 4, the patient has demonstrated that he is willing to change, but remains with cravings, anxiety, and mood swings. The provider described the patient as irritable and was not ready to take accountability for his issues. Dimension 5 is satisfied, as the patient has not yet learned coping strategies other than substances to deal with his psychiatric symptoms and requires more time in this structured environment. Finally, dimension 6, the patient has relayed that his primary social contacts continue to use and he has been unable to maintain sobriety in his current social environment. The patient requires further treatment so that he can learn to tolerate his social stressors. The patient requires a safe and stable living environment in order to develop his recovery skills thus qualifying for ASAM Level III treatment, similar to what patient has received at the current residential facility. Given the severity of the patients illness, the residential substance use disorder treatment level of care was and is medically necessary for treatment of this patient.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 psychiatry with expertise in addiction 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: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested septoplasty and turbinate resection for treatment of his deviated septum and nasal obstruction.  Findings:  The physician reviewer found that nasal surgery has not been found to be effective in the treatment of obstructive sleep apnea secondary to nasal obstruction, as it does not significantly reduce apnea/hypopnea indices. The proposed surgery is not medically necessary and is not in accordance with generally accepted standards of medical practice at this time. According to a recent paper by Aurora and colleagues, Systematic and methodical investigations are needed to improve the quality of evidence, assess additional outcome measures, determine which populations are most likely to benefit from a particular procedure or procedures, and optimize perioperative care. Based on currently available outcome data, the medical necessity of nasal surgery in this patient population has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for testosterone injections. The submitted documentation supports the medical necessity of the requested medication. Low testosterone can lead to complications such as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment, in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. The patient has failed therapy with transdermal testosterone. The patient will benefit from intramuscular testosterone therapy. Therefore, the requested testosterone injections are medically necessary for 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 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

The parent of a three-year-old female enrollee has for speech therapy services for treatment of her speech apraxia.  Findings:  The physician reviewer found that it is clear that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. These reviewers conclude that this meta-analysis shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Verbal apraxia, or apraxia of speech, is an impairment in planning and coordinating movements for speech production as stated in the Nelson Textbook of Pediatrics. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. Lewis and colleagues note that this type of impairment is frequently seen after stroke or with congenital disorders that affect the brain such as Down syndrome, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, these children are at risk for reading and spelling problems in addition to articulation problems. Communication at all levels may ultimately be impaired.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a nuclear thyroid scan with vascular flow. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Iodine-131 (I-131) thyroid scan is an appropriate study for assessing thyroid malignancy, residual malignancy post-thyroidectomy, and recurrent or distant metastatic disease post-thyroid cancer treatment in appropriate patients. Post-thyroidectomy patients are assessed for recurrence or metastases by measuring serum thyroglobulin level. If thyroglobulin levels are within normal range, residual or recurrent thyroid malignant disease is unlikely. According to American College of Radiology, whole-body scintigraphy (I-131) is not utilized in low-risk patients without suspicion for recurrence and normal thyroid ultrasound. It has no role in low-risk patients who have had a lobectomy. This patient is status post thyroidectomy. She had normal serum thyroglobulin and a normal ultrasound of the neck. The patient is at low risk for recurrent or metastatic thyroid malignancy. Therefore, the requested nuclear thyroid scan with vascular flow is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 two-year-old male enrollee has requested for speech therapy and physical therapy for treatment of the enrollees developmental delays. Findings:  The physician reviewer found that there is robust medical literature supporting the value of speech therapy in this setting. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in their meta-analysis of multiple medical journal articles. Prelock, et al. discussed the evaluation and successful treatment of speech-delayed children with speech and language therapy. A study by Goorhuis-Brouwer and colleagues examined speech-delayed children, both those with and without developmental delay, and found that both of these categories of children are candidates for successful speech therapy. A study by Carboni and colleagues states that muscle stretching by physical therapists is essential for hypotonic children to experience improved motor function. Parush and colleagues found that hypotonia will continue to affect large motor groups throughout childhood and therefore continuous physical therapy is necessary to address these deficits. Given the available literature supporting the use of physical therapy in this setting, the requested physical therapy is medically necessary for the treatment of this patients documented motor skill deficits.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: At issue is whether the medication, Belsomra 20 mg tablets, #60 tablets per 30 days is medically necessary to treat the patients medical condition. This is a patient with chronic insomnia and sleep apnea that started a trial of the medication, Belsomra in 7/15. Regular use of Belsomra 40 mg at bedtime was documented from 7/16 through 1/20. Follow-ups with the provider show trials of Ambien, Lunesta, Rozerem and Sonata with the loss of insomnia benefit with time. The patient was intolerant of trazodone, Remeron, Elavil, Prozac, Paxil and Zoloft. The patients insomnia severity index was 25.5 (severe) and the fatigue severity scale was 53 (severe) in 2016. The insomnia severity index was 16-20 (moderate) and fatigue severity scale 31 (moderate) in 1/20. Few medications treat only chronic insomnia. Medications such as antidepressants (such as Prozac or Zoloft), anti-anxiety medication (such as temazepam) or antipsychotics (such as clozapine or Haldol), are given for their side effects to induce sleep, for insomnia. Belsomra was one of the first medications specifically for the treatment of chronic insomnia. The American Association of Sleep Medicine (AASM) practice guideline lists Belsomra as the first choice of medication for chronic insomnia treatment. Management of sleep apnea and insomnia can be challenging. In this case, the balance that satisfies the patients insomnia symptoms and at the same time affords the patient to be compliant with CPAP, appears to be met. Review of literature demonstrated that 40 mg is a dose that is given in many studies. Side effects increased to 30% with the 40 mg dosage but Hong et al found no adverse effect on sleep apnea with a dose of 40 mg.  In this case, the patient has done well on a 40 mg dose for many years. Reducing the dose of Belsomra may be a long-term goal that is best left to the discretion of the treating provider.   Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested two hours per week of speech therapy or treatment of the enrollees autism.  Findings:  The physician reviewer found that in the clinical literature, Carey and colleagues noted that language deficits are one of the core aspects of autism, and speech therapy provides professional help and guidance in communication development for patients with autism. A study by Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to determine factors related to the development of spoken language. Overall, the only significant predictors were motor imitation and number of hours of speech and language therapy. The researchers reported that patients with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions in the peer-reviewed medical publications and found that the evidence supported the claim that effective interventions exist to teach communication skills to children with autism. Further, the author indicates that teaching language to children with severe communication deficits has profound impact on the lives of children and the people who interact with them as language skills can make a tremendous difference in the ability of children to control their environment. In addition, language skills have been found to be an adaptive alternative to highly disrupted forms of communication. The language evaluation in this patients records documents impairment with difficulty understanding complex speech both receptively and expressively. Given the support in the scientific data on the effectiveness and importance of speech therapy in young patients with ASD, the requested therapy is medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested acute inpatient services provided for treatment of the enrollees eating disorder and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue in this patients case.  The American Psychiatric Association has provided guidelines for determining the appropriate level of care for patients with eating disorders.  Residential treatment may be the appropriate level of care for patients with poor to fair motivation or for patients who are preoccupied with intrusive, repetitive thoughts four to six hours per day.  Per the submitted documentation, this patient endorsed significant discomfort with eating, and she spent a large portion of the day thinking about meals and her weight.  Based upon the medical records, this patient required supervision during meals.  The current medical evidence supports residential level of care in this setting.  Thus, residential treatment provided from the time frame specified was medically indicated for the treatment of this patient.  However, the patients vital signs and weight on admission do not support acute inpatient level of care provided from the time frame specified.  All told, a portion of the services at issue was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a FlexiTouch compression device with two garments. In this case, the unique features of the patients condition, including her severe pain, intractable restless leg syndrome, chronic lymphedema, and hemodialysis needs, require an advanced pump with individual segment calibration. As the patients PD catheter has been removed, the requirement to maintain both regular dialysis appointments and lymphedema clinic appointments would be unreasonable. The provider has stated that a basic pump is insufficient for this patients needs and recommended the Flexi-Touch device as the most appropriate device for the patient. The submitted documentation supports the medical necessity of the requested device. Therefore, FlexiTouch compression device with two garments is medically necessary for the treatment of this patient.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 vascular 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.