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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for low level laser therapy for treatment of the enrollees recurrent breast cancer with lymphedema. Findings:  The 3 physician reviewers found that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has chronic lymphedema, which is difficult to treat due to chronic fibrosis. Low level laser therapy is a photochemical treatment used for soft tissue injury, chronic pain, and wound healing. Results from a randomized, single crossover trial of the treatment of patients with post-mastectomy lymphedema with low level laser therapy was found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately 33% of patients with post-mastectomy lymphedema at three months after treatment. Given the support in the peer-reviewed literature, the request for low level laser therapy is 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 service is 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 internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested partial hospitalization program (PHP) services provided for treatment of his anorexia nervosa. The physician reviewer found that although the patient had a significant eating disorder complicated by global negative schemas and depressiveness, the clinical documentation provided did not support the medical necessity of the PHP services. During the treatment course, the patient demonstrated steady improvement.  The patient was in the action stage of treatment. His weight was up from admission. He was normotensive, with no orthostatic changes, bradycardia or tachycardia. He was taking classes two mornings per week and participating in social activities. The patient was reported to be eating 100% of his meals and, he was less depressed. The treatment team had a reassuring meeting with the patients family.  The patient denied any eating disordered behavior. His vital signs remained stable, he was 92% of his ideal body weight, and he was gaining weight on a positive trajectory. He was making his own meals and consistently following his meal plan, both within and outside the program. He was stable on an adequately dosed serotonergic enhancing medication. Although the patient continued to require long-term specialty care, there is a lack of evidence to suggest that he would have experienced a recrudescence of the symptoms if transitioned to a less restrictive setting, such as an intensive outpatient program (IOP). In sum, based on the documentation provided, the PHP services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested speech therapy for treatment of the enrollees receptive and expressive language delays. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder.  This patient has severe expressive language delay, as well as delays in receptive language, play, and cognition. These deficits are significantly impairing his ability to communicate effectively and function socially. They may also be negatively impacting his self-care and feeding skills.  The current medical literature supports the requested therapy in this patients case.  All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old male enrollee has requested chemical dependency residential treatment level of care services for his behavioral health issues. Findings: The physician reviewer found that based on review of the available records, this patient had several issues including substance dependence, major depressive disorder, and mixed personality disorder. During his hospital admission, he remained at risk for suicidal behavior. He was admitted after an overdose. Additionally, the progress notes indicate that he continued to feel helpless, hopeless, and impulsive. Finally, he called his one contact to inform him that he was acutely suicidal, but was not open about this to the staff, putting him at an even higher level of risk. The records indicate that he showed motivation to enter rehabilitation and had family support to do so. However, he lacked coping skills and insight into the nature of his problems. According to the American Psychiatric Association (APA) treatment guidelines, this patient meets the criteria for continued stay at the inpatient rehabilitation level for treatment of substance abuse from said date forward.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for high dose rate (HDR) brachytherapy combined with external radiation. The National Comprehensive Cancer Network (NCCN) guidelines state that low dose rate (LDR) or HDR brachytherapy can be added as a boost to external beam radiation therapy plus androgen deprivation therapy in patients with high-risk prostate cancer being treated with curative intent to minimize acute or late toxicity while improving biochemical control. Similarly, the European Association of Urology (EAU) guidelines recommend external beam radiation therapy with LDR or HDR brachytherapy boost in combination with long-term androgen deprivation therapy for patients with high-risk localized prostate cancer. As this patient has a diagnosis of Gleason 3+4=7 prostate cancer with an elevated prostate specific antigen (PSA) of 44.4, the requested treatment is consistent with the NCCN and EAU guidelines. All told, HDR brachytherapy combined with external radiation is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in urology 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 authorization and coverage for lurbinectedin injection. The U.S. Food and Drug Administration (FDA) approves the use of lurbinectedin for the treatment of metastatic small-cell lung cancer in adults with disease progression on or after platinum-based chemotherapy. Given that the National Comprehensive Cancer Network (NCCN) guidelines for neuroendocrine and adrenal tumors do not endorse the use of lurbinectedin, and the lack of evidence in current medical literature supporting its use in this clinical setting, the requested medication is not medically indicated. Therefore, lurbinectedin injection is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 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 an Orthofix bone growth stimulator (HCPCS E0748).The current medical literature supports that the requested device is medically necessary. Researchers recommended the use of electrical bone growth stimulation as an option for patients younger than 60 years of age, since a positive effect on fusion has been observed. The same, however, could not be stated for patients over 60, because electrical bone growth stimulation did not appear to have an impact on fusion rates in this population. In another review, Morone and Feuer concluded that cases in which a spine surgeon may want to consider adjunctive electrical stimulation include patients undergoing multilevel fusion or reoperation, those who use tobacco, and those with disorders of low bone mineral density (that is, osteoporosis). Morone and Feuer found that the overall fusion rate of the electrical stimulation treated patients (84%) compared with the non-electrical stimulation treated patients (64%) was statistically significant.In this case, the patient was diagnosed with grade 2 spondylolisthesis at L5/S1, spinal and foraminal stenosis due to spondylosis and disc degeneration, and lumbar radiculopathy. The patient underwent a staged lumbar fusion procedure including L5/S1 discectomy, bilateral foraminotomies, insertion of an interbody device, arthrodesis, and insertion of an anterior plate in the first stage of surgery, followed by pedicle screw placement, posterolateral fusion with autograft and allograft bone, and arthrodesis at L5/S1 in the second stage of surgery. Current evidence based medical literature indicates that bone growth stimulation has a positive effect on fusion for patients at high risk for pseudoarthrosis. The present request is also supported by the combination of risk factors including large surface area to fuse. Under these circumstances, the requested Orthofix bone growth stimulator (E0748) is medically necessary to treat the patients medical condition.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 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: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested intravenous immune globulin (IVIG) therapy for the treatment of her unspecified immune disorder and chronic sinusitis. Findings:  The physician reviewer found that there is no evidence the patient has undergone appropriate laboratory testing to establish immune deficiency. Without the results of the laboratory studies listed above, IVIG therapy cannot be supported for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom orthotics. Findings: The physician reviewer found the current guidelines indicate that orthopedic footwear including shoes, inserts, or modifications to shoes for patients without diabetes are not considered medically necessary. Some bracing may be indicated if the braces are on a shoe that is an integral part of a medically necessary leg brace. These criteria are not supported in the documentation provided. Review of the documentation provided does not indicate that the foot orthotic would alleviate the patients condition and therefore the requested custom orthotics are not medically necessary. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 reimbursement for mobile cardiac outpatient telemetry (MCOT). Findings:  The physician reviewer found that cardiac monitoring during recurrent symptoms with non-real-time monitoring devices, such as 48-hour Holter monitoring or event monitoring, would have been sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Similarly, self-activated non-real-time and non-continuous monitoring devices are effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real-time monitoring devices with auto-triggering capability are appropriate. There is a lack of documentation that the patient was unable to manage these standard monitoring devices or that these options were used to evaluate the patients condition. Current expert consensus guidelines endorsed by several national organizations also consider patient activated event recorders and other offline monitoring devices appropriate initial tests for evaluation of supraventricular dysrhythmias. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques. Given these findings, MCOT was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the MCOT was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested binaural hearing aids for treatment of his bilateral hearing loss. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested binaural hearing aids.  There is a lack of support for the requested devices in this clinical setting.  The records do not show that the hearing aids were prescribed by an otolaryngologist after review of an audiological evaluation.   This patient has a severe form of hearing loss, but he has been using hearing aids.  There is no rationale supplied for new hearing aids as the patients current devices already provide as much benefit as can be expected based on the audiograms submitted for review.  All told, the requested binaural hearing aids are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old male with a history of articulation delay and phonological disorder. He has been receiving speech therapy since November 2005. The initial goals included production of /l/ in initial, medial and final positions. Long-term goals included production of /l/ and /r/ and fricatives /s/, /z/ and /sh/ at the sentence level.The patients parent has requested reimbursement for the speech therapy the patient has received as well as prospective authorization for additional therapy. The Health Plan has denied this request indicating the submitted documentation does not demonstrate the need for speech therapy.The Health Plans denial should be upheld. There is a lack of clinical documentation supporting the necessity of speech therapy. The short-term goals included in the therapists evaluations only address part of the first long-term goal. The remainder of the long-term goals are not addressed. In addition, there are no follow-up reports documenting attainment of short-term or long-term goals. Furthermore, the individual progress notes are not adequate to demonstrate objective improvement toward goals. As such, there is insufficient evidence to establish that speech therapy was or is medically warranted in this case.Accordingly, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for unilateral cochlear implant. The U.S. Food and Drug Administration (FDA) approved MED-ELs cochlear implant for single-sided deafness (SSD) and asymmetric hearing loss (AHL) for patients five years of age and older in 2019. However, to fully meet criteria for cochlear implant for this indication, the FDA requires that individuals with SSD or AHL must have at least one (1) month experience wearing a Contra Lateral Routing of Signal (CROS) hearing aid or other relevant device and not show any subjective benefit. The documents submitted for review do not demonstrate that the patient used a CROS hearing aid, bone-anchored hearing aid (BAHA), or other relevant hearing aid for 1 month. There are few studies comparing cochlear implants with other rehabilitative interventions, such as an air-conduction CROS hearing aid or BAHA. Medical literature found that a BAHA was more efficacious than CROS hearing aids in patients with unilateral severe-to-profound hearing loss, and that cochlear implants, BAHA, and CROS hearing aids all improved hearing-related quality of life. However, the meta-analysis could not support that cochlear implants were more beneficial than BAHA or CROS hearing aids. Medical literature reported on a combined prospective randomized controlled trial of patients with single-sided deafness or asymmetric hearing loss who were initially provided CROS and headband-based bone-conduction hearing aids. The authors found that cochlear implants, BAHA, and CROS devices all improved quality of life. This patients clinical documentation does not support that the patient is not a candidate for treatment with a BAHA for the treatment of unilateral hearing loss. All told, the requested unilateral cochlear implant is not medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 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.