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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical procedure of upper airway stimulation (UAS) of the hypoglossal nerve for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  The 3 physician reviewers found that there is a lack of sufficient support in the peer-reviewed literature showing UAS is superior to CPAP treatment. According to colleagues, UAS is a potential therapy for continuous positive airway pressure (CPAP)-refractory obstructive sleep apnea by hypoglossal stimulation using an implantable, programmable neurostimulator. In this case, the records submitted for review do not demonstrate that the patient has tried and failed an adequate trial of CPAP. Given the lack of support showing the patient has failed CPAP treatment, the UAS of the hypoglossal nerve has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested procedure is 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 reviewer number one is board certified in otolaryngology 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 otolaryngology 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 otolaryngology 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 49-year-old female enrollee has requested Norco, Vicodin, and a pain patch for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. Long-term opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. It is in the patients best interest to wean off all these opioids and continue in a multidisciplinary program. All told, the requested Norco, Vicodin and pain patch are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested transfer to an acute care hospital for treatment until he is stable to resume chemotherapy (preferred); or transfer to an acute care rehabilitation hospital until he is stable to resume chemotherapy; or to remain in a long-term acute care hospital (LTACH) for treatment until he is stable to resume chemotherapy are not medically necessary. At the time of initial presentation, this patient was independent with his activities of daily living (ADLs). Since diagnosis, he has been in the hospital with evidence of significant physical and cognitive decline. Currently, he is being cared for in a LTACH with the goal of improving his functional status. He has not been receiving optimal occupational and physical therapies primarily due to refusal and ongoing medical issues. A physical therapy evaluation reports that he requires assistance to sit and stand, and is dependent for all ADLs, including dressing, toileting, and feeding. Although the patient indicates that his primary goal is to improve his condition to be stable enough to resume treatment with chemotherapy, returning to that level of function would require improvement in occupational and/or physical therapy. The patient does not require acute inpatient treatment as his medical issues can be managed in a LTACH. However, treatment in a LTACH is not appropriate as he has been described as a poor acute rehabilitation candidate as he has refused participation in occupational and physical therapies. Moreover, he does not meet the criteria for acute rehabilitation as his medical needs are too complex and he is unable to participate in the minimal requirement for acute rehabilitation. The records indicate the patient is at the level of supportive or palliative rehabilitation with the goal of improving his quality of life and ability to perform self-care. He would benefit from psychological support and a formal palliative care evaluation to reassess his goals of care. Based on the documentation provided for review, his current medical issues preclude transfer to a higher level of care or resumption of chemotherapy. Thus, the requested transfer to an acute care hospital for treatment until he is stable to resume chemotherapy (preferred); or transfer to an acute care rehabilitation hospital until he is stable to resume chemotherapy; or to remain in a LTACH for treatment until he is stable to resume chemotherapy are not medically necessary.Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment center services for evaluation of the enrollees behavioral health conditions. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness.  In this patients case, she was unable to maintain sobriety in the outpatient setting.  Drug use, heroin and benzodiazepines in particular, dominated her daily routine, permeated functional domains and jeopardized her well-being.  Her peer group, social interactions and family dynamics were not conducive to clean and sober living.  She was deemed to be high risk for relapse.  She had significant psychiatric comorbidity and a poorly defined self-concept.  She was malnourished and unhealthy upon presentation.  She had failed less restrictive treatment interventions.  Per the records, the dates in dispute were aimed at both consolidating the gains made in treatment and facilitating a successful transition to a less restrictive setting.  Based on the longitudinal history and medical documentation, the patient would have likely promptly relapsed and required re-admission in the absence of the disputed residential programming.  Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment, considering the extent of her illnesses and suboptimal outcomes of previous treatments, aligned with community standards.  Final Result: The reviewer determined that the services at issue were 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued acute inpatient care. Central nervous system (CNS) tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV. Anaplastic astrocytomas and glioblastoma multiforme are high-grade tumors that are best treated with resection, radiation therapy, and chemotherapy. This patient has experienced multiple complications from her brain tumor such as edema, mass effect, and stroke. The providers have documented that the patient has been nonverbal for many of her evaluations. According to the available medical records, the patient was clinically stable for discharge. Therefore, the continued acute inpatient care was not and is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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 internal medicine with subspecialty certifications in medical oncology and hematology 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  speech therapy at a frequency of two sessions per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patients speech was at a 12 month receptive level and expressive language was at a 9 month level when tested 6 months ago. In a more recent evaluation, the patient was noted to have significant delays in his expressive speech, as well as articulation deficits. The etiology of his speech delay is due to a severe developmental delay in his maturation of speech. Regarding the medical necessity of speech therapy, it is the medical communitys standard practice to offer speech therapy to a two year-old whose speech is significantly delayed for his age.  There is robust medical literature supporting speech therapy in this speech delayed toddler population. According to Law and colleagues, children with speech delay can be readily treated. Two-year olds, who tested below the 10th percentile, as this patient did, require and did benefit from speech therapy in two different studies (Emmanuel, et al; and Buschman, et al).   All told, based upon the patients recent speech therapy evaluation, speech therapy is medically indicated for this patient, at a frequency of two hours per week.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for referral for consultation with an oral maxillofacial surgeon. The patient has a maxillofacial skeletal deformity. Based on the photographs and x-rays, the patient may require orthognathic surgery as well as orthodontics to repair her condition. Consultation with an oral surgeon is appropriate to assess if the patient is a candidate for orthognathic surgery. Correction of the patients maxillofacial skeletal deformity would improve her musculoskeletal and dento-osseous relationships and should help alleviate this patients associated muscular disorders and facial pain. Given these findings, the requested referral for consultation with an oral maxillofacial surgeon 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 oral and maxillofacial 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: Medical Necessity
Decision: Upheld

The patient is a 30-year-old male with a history of hyperhidrosis status post endoscopic thoracic sympathectomy. Since the procedure, the patient has experienced compensatory hyperhidrosis. This is a known possible side effect of thoracic sympathectomy. The patient now wants to undergo a reverse sympathectomy. The Health Plan has denied this request.There is no evidence to support authorization of a reverse sympathectomy. There is no data supporting the long-term efficacy and safety of the procedure. Indeed, the patients provider indicates he has performed a small number of these procedures with varying degrees of success. Given the lack of data supporting the safety and efficacy of the requested procedure, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 30-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from acute right-sided abdominal pain due to gallstones and subsequent gallbladder inflammation (cholecystitis). She required a series of blood and ultrasound tests to make this diagnosis. Other diseases that are in the differential diagnosis of her presenting symptoms include gastritis, peptic ulcer disease, hepatitis, pancreatitis, urinary tract infection and/or stone among others. A prudent layperson would reasonably seek immediate medical attention due to the severity of pain as well as the potential jeopardy to other body organs.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee has requested Subutex for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the available evidence indicates that the use of Suboxone is preferred, but not mandated, for unsupervised maintenance. In this case, the patients physician describes the patients headaches and inability to progress to a lower dose as intolerability to Suboxone. That he was able to reduce his intake of Subutex to 2mg per day is an indication that the patient achieved better results with Subutex than Suboxone, and therefore, supports the continued use of Subutex this setting.
Appeal type: Urgent Care
Decision: Overturned

A 62-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from an acute (although recurrent) headache of sufficient severity of pain that one would reasonably believe failure to obtain immediate medical attention could result in serious jeopardy to health, serious impairment to bodily functions, or serious dysfunction of a bodily organ.  Although she had a history of headaches in the past, the patient reported that her headache was severe.  The fact that her heart rate was elevated is evidence of severe pain.  In addition, her history of hypertension does put her at risk for a variety of potentially life-threatening disorders including hypertensive emergency manifesting with severe headache, intracerebral hemorrhage, and others.  It was important that the patient receive medical evaluation and treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result:  Three reviewers determined that the diagnostic procedure 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 has requested an enhanced external counter pulsation (EECP) for treatment of her chest pain.  Findings:  The physician reviewer found that there is a lack of support for the requested service in this clinical setting. EECP is indicated for the treatment of patients with angina refractory to conventional therapy which would include coronary artery bypass graft (CABG), PCI/Stenting, as well as maximally tolerated anti-ischemic therapy. The records provided do not support intractable angina. In addition, the provider recommended appropriate cardiovascular evaluation stating that the patients ischemic burden would need to be identified to determine whether additional intervention would be required. For these reasons, the requested service is not medically necessary for treatment of the patients medical condition.   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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Avastin, Torisel, Opdivo, and Faslodex injection. The requested regimen of four medications has not been shown to improve net health outcomes in patients with metastatic breast cancer in randomized controlled clinical trials. In addition, there is a lack of data on the potential toxicities associated with this combination of medications. Moreover, the regimen is not recommended in the National Comprehensive Cancer Network (NCCN) guidelines and is not supported by major drug compendia. The use of Opdivo for breast cancer is currently the ongoing subject of clinical trials while Avastin is rarely used in breast cancer. Overall, there is a paucity of scientific data demonstrating the safety and effectiveness of this medication regimen in patients with breast cancer. Given these findings, the requested medication regimen consisting of Avastin, Torisel, Opdivo, and Faslodex injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies. Findings:  Three physician reviewers found the requested medication regimen consisting of Avastin, Torisel, Opdivo, and Faslodex injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.Final Result: The reviewers determined that the requested medication regimen consisting of Avastin, Torisel, Opdivo, and Faslodex injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollees parent has requested authorization and coverage for In-Plan social language speech therapy program. This patient has autism with impairment of pragmatic language, the severity of which was likely underscored with the testing tools administered. The provider noted intermittent errors on substitution of th with /d, f/ and gliding of r on testing, but found that she had age-appropriate pragmatic language skills. Her parent has expressed concern regarding the patients ability to communicate with her peers. This patient is at risk of being socially isolated because of her impairments in the appropriate social use of pragmatic language. Researchers have recommended that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. Researchers have also discussed methods of exploring deficits in pragmatic language in children with autism using: 1) the Pragma test; 2) the Social Interaction Deviance Composite (SIDC) of Childrens Communication Checklist-2 (CCC-2); and 3) the Theory of Mind subtest of the Developmental Neuropsychological Assessment, the results showed that children with autism differed from typically developing children in questions demanding context utilization. These tests were not used to evaluate this patients pragmatic language skills. Based on the available documentation, the requested In-Plan social language speech therapy program is medically necessary for treatment of this patients medical condition.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.