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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for additional speech therapy over a six-month period Speech therapy for a young patient with autism spectrum disorder should be provided on a consistent and frequent basis. Decreasing the frequency to is likely to result in regression, which will increase this patients disability. Weekly speech therapy is consistent with the American Academy of Pediatrics recommendations. Reporters conducted a meta-analysis of 25 studies on speech and language therapy interventions for children with primary speech and language delay or disorder. The reporters concluded that speech and language therapy interventions in young patients with expressive phonological and expressive vocabulary difficulties provide positive outcomes. Reporters noted that the ability to communicate effectively with others is central to childrens development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. For this patient with articulation/phonological disorder and mixed expressive and receptive language disorder, 60-minute speech therapy sessions once per week is appropriate to provide the patient with continued support and prevent regression. Therefore, the requested additional speech therapy over a six-month period are medically necessary to decrease disability and  correct or ameliorate the patients behavioral conditions.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 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 authorization and coverage for Entresto 24 mg - 26 mg tablets. Findings:  The physician reviewer found that the use of an angiotensin II receptor blockers (ARBs), such as losartan, is indicated during an acute heart failure event. The authors note that for patients on a low dose of ARB, a gradual titration approach maximized attainment of the target dose of Entresto (sacubitril/valsartan) for long-term management. In this case, the patient is recovering from heart failure and cardiogenic shock in the setting of acute nonischemic cardiomyopathy. The provider has instructed the patient to discontinue losartan and start on Entresto. Therefore, Entresto 24 mg - 26 mg tablets 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 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is investigational for treatment of the enrollees neck pain and headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an 11-year-old male enrollee requested authorization and coverage of a pediatric neurologist for the treatment of attention deficit hyperactivity disorder.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX Reflux Management System (CPT 43284). Findings:  The physician reviewer found that here is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX Reflux Management System is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX Reflux Management System can be recommended. Additionally, LINX Reflux Management System has been associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not demonstrate that LINX Reflux Management System is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, LINX Reflux Management System (CPT 43284) is not likely to be of greater benefit than other treatment options. Final Result: Two of the three physician reviewers found  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 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for botulinum toxin for treatment of the enrollees migraines. Findings:  The physician reviewer found that The physician reviewer found there is sufficient support for the requested services in this clinical setting. This patient has been treated with an adequate number of preventive medications, without success.  Botox has established efficacy, not only in episodic migraine, but also in chronic daily headache as well as mixed headache disorders. The medical evidence supports botulinum toxin in this patients case. All told, the requested botulinum toxin is likely to be of greater benefit than other available treatment options. Three reviewers determined that the requested services are 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 reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in 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: A female enrollee has requested authorization and coverage for Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patient has longstanding symptoms which are limiting despite treatment with acetaminophen, ibuprofen and corticosteroid injection. Based on the available documentation, hyaluronic acid injection is a reasonable treatment option. All told, the requested Synvisc One injections are supported as medically necessary for treatment of this patients knee osteoarthritis.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 ***. 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 59-year-old female enrollee has requested for enhanced external counterpulsation for treatment of her angina.   Findings:  Two physician reviewers found that it does not appear that repeat coronary angiography was considered post CABG; there are no documented contraindications to this procedure. The standard treatment in this case would first be a trial of maximal medical therapy and reexamination as to why she had angina after surgical revascularization, prior to consideration of EECP. EECP could be later reconsidered if the patient has continued Class III to IV angina, despite maximal medical therapy and the inability to further revascularize the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested brain imaging tomographic (SPECT) scan for evaluation of his diagnosis of Parkinsons disease.  Findings:  Two physician reviewers found the patient has a clinical diagnosis of Parkinsons disease, with rest tremor and a history of falls.  Parkinsons disease remains a clinical diagnosis, suggested by asymmetric rest tremor, rigidity, bradykinesia, and imbalance.  There is a lack of support for the services at issue in this clinical setting.  There is inadequate clinical information submitted to indicate that SPECT study would alter therapy in this patients case.  Appropriate care would be to try treatment for Parkinsons disease, which is the clinical diagnosis, and monitor for results.  Thus, the brain tomographic (SPECT) scan is not likely to be of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested authorization and coverage for an occupational therapy assessment and occupational therapy for evaluation and treatment of the enrollees stated condition of a sensory processing disorder.  Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman; and Polatajko and Cantin). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children when sensory processing concerns exist. Occupational therapy, although anecdotal support exists, does not have sound evidence for effectiveness as few well-controlled studies exist that examine the effectiveness of frequently used pediatric occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life (Polatajko and Cantin). A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. This patient has underlying hypotonia, fine motor delays and sensory processing issues. Thus, the requested occupational therapy evaluation to determine the patients specific deficits and subsequent occupational therapy services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old man with a history of osteoarthritis in his left knee. He is status post a meniscectomy. The patient has received Synvisc injections without significant relief. His provider has recommended a trial of therapy with the Bionicare system. The Health Plan has denied this request on the basis that the requested device is not medically necessary for treatment of the patients condition.The efficacy of an electric stimulator such as the Bionicare system for the treatment of pain secondary to osteoarthritis remains unproven at this time. No prospective study has been conducted to warrant its general use. The risks, benefits and long-term results of such therapy remain unknown. There is no evidence that the use of the Bionicare system is likely to result in an improved clinical outcome. Therefore, I have determined the requested device 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 5-year-old male enrollee has requested pediatric speech therapy, including but not limited to group therapy for pragmatic communication skills (social skills training) and neurosensorimotor therapy to improve self-regulation, sensory integration and sensory modulation and praxis for treatment of the enrollees pervasive developmental disorder and autism. Findings:  The physician reviewer found given his normal expressive and receptive language, as well as the fact that the patient is receiving other services that improve social language pragmatic delay, the request for pediatric speech therapy, including but not limited to group therapy for pragmatic communication skills (social skills training) was not and is not medically necessary in this clinical setting. The neurosensorimotor therapy to improve self-regulation, sensory integration and sensory modulation and praxis was and is medically necessary for treatment of the patients medical conditions. Sensory integration techniques enable the occupational therapist to assist developmentally delayed children to develop the ability to integrate into normal motor and personal-social patterns to function with their peers. Sensory integration therapy is supported in the medical literature as to its long-term value in autistic children. The study by Miller and colleagues reports significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children. In this case, the patient presents with sensory dysfunction with noted delayed processing and motor planning abilities. Thus, the services at issue were and are medically necessary to assist with remediating his sensory dysfunction. As such, neurosensorimotor therapy to improve self-regulation, sensory integration and sensory modulation and praxis to overcome this unique autistic behavior is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  This enrollee was receiving Applied Behavioral Analysis (ABA) services due to his developmental delays in social interaction, communication, and maladaptive behaviors. After review of the medical records it was determined that Applied Behavioral Analysis is medically necessary. Multiple sources support that applied behavioral analysis is an appropriate and effective treatment behaviorally and educationally for autistic spectrum disorder individuals with social delays, language and communication delays, and difficulties in adaptive functioning.  Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and Child and Adolescent Psychiatry and is actively practicing.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee requested authorization and coverage of an MRI of the lumbar spine. The Health Pan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees leg pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis performed for a breast cancer screening.  Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  She has a family history of breast cancer with a mother who was diagnosed with breast cancer. She underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, she had a hand-held whole breast sonography. The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breast tissue was described as heterogeneously dense. The Health Plan has denied reimbursement for bilateral digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 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 particular patient, her breast tissue was described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, 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. Therefore, bilateral digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested hair removal via electrolysis in preparation for vaginoplasty for treatment of her gender dysphoria.  Findings:  The physician reviewer found that the arguments for electrolysis hair removal in anticipation of vaginoplasty are strong, in that hair removal cannot be easily accomplished after the surgery and there are risks of infection associated with persistent hair growth in the area following surgery. However, in this case the patient has not yet met criteria for approval of the gender reassignment surgery. Although the hair removal procedure is considered to be part of the gender reassignment surgery and should ultimately be authorized if and when the surgery is to be performed, the request to undergo electrolysis at this time is premature as the patient has not yet met criteria for gender reassignment surgery. Further, it is possible that the amount of electrolysis needed for adequate hair removal may decrease in the coming months as the hormone replacement therapy takes effect. Therefore, the request for electrolysis is not medically necessary at this time.  Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology 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 gene testing that was performed for evaluation of the enrollees indeterminate thyroid nodules. Findings: Two physician reviewers found that the cytopathology of the 1.5 cm thyroid nodule was consistent with a follicular neoplasm. The risk of malignancy is 15 to 30% in follicular neoplasm nodules. The Bethesda System recommends a diagnostic thyroid lobectomy for this type of nodule. The newest 2015 American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. The risk of malignancy is 15 to 30% in follicular neoplasm nodules. The finding of positive medullary thyroid carcinoma gene allows the surgeon to determine the best course of action. Final Result: Two of three physician reviewers determined that the services at issue were likely to have been 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.