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

A 52-year-old female enrollee has requested for a PET scan for evaluation of her lipoma versus liposarcoma. Findings:  The physician reviewer found that the literature regarding liposarcoma and PET scan is limited. There are a few studies showing good sensitivity and specificity for higher-grade tumors. However, it is difficult to differentiate lipoma from low-grade sarcoma. CT or ultrasound guided biopsy would be a more appropriate next step rather than a PET scan.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old female enrollee has requested the medication Xifaxan (1/2 tablet three times daily for ten days for the treatment of the enrollees small intestinal bacterial overgrowth (SIBO). Findings:  The physician reviewer found that all of the alternative antibiotics recommended by the Health Plan are absorbed through the gastrointestinal (GI) tract. Neomycin has been considered a non-absorbable antibiotic by some, but oral administration can be associated with malabsorption and nephrotoxicity so it is not a preferred antibiotic and contains a black box warning from the Food and Drug Administration.  Furthermore, neomycin is not approved for children less than 18 years of age. The other antibiotics that were recommended by the Health Plan have systemic effects and therefore were not considered suitable for the patient by her prescribing physician. Of the absorbable antibiotics, tetracyclines are generally not used in young children because of concerns over bone and dental health. Fluoroquinolones and ciprofloxacin for example, negatively affect growing cartilage in young children.  Norfloxacin is used mainly for the treatment of urinary tract infections and prostatitis and is not approved for patients less than 18 years of age. Metronidazole also has considerable safety issues. In the United States, Xifaxan is the only non-absorbable antibiotic with a low-complication profile that is available for the treatment of SIBO. There are studies that show it is an effective agent for the treatment of SIBO. Although the FDA approves Xifaxan for children 12 years and older, this patient, at 11 years of age was within months of that age at the time the medication was prescribed and thus its use in this setting was medically reasonable.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home birth with water birth. There is a lack of support for the requested services in this clinical setting. The American College of Obstetricians and Gynecologists (ACOG) noted that women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with a more than twofold increased risk of perinatal death (12 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.40.6 in 1,000). ACOG reported that there is a lack of adequate randomized clinical trials of planned home birth. The medical evidence has not shown that a home water birth is as safe as delivery within a hospital environment. Therefore, the requested home birth with water birth is not medically necessary for the treatment of this patient.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 obstetrics and gynecology 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 shower bench with back support. The records reviewed document that this patient has multiple pain complaints with diagnoses including fibromyalgia and complex regional pain syndrome (CRPS). The recommended treatment of fibromyalgia and CRPS involves analgesics and physical activity to the extent possible. In addition, desensitization to stimuli is a classic modality that has long been employed for the treatment of CRPS. In this case, the patient has undergone multiple examinations that have not revealed neurological, musculoskeletal, or other deficits suggestive of functional impairments with respect to bathing or other basic self-care activities. The provider noted that the patient has demonstrated a normal to a mildly ataxic gait. The patient reports that she is unable to stand for prolonged periods of time. However, there is a lack of evidence that the patient cannot tolerate standing for the duration of a shower to perform basic hygiene. The records do not include a formal therapy evaluation to establish that the patient requires a shower bench with back support to perform her bodily hygiene activities. Therefore, the requested shower bench with back support is not medically necessary for treatment of 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 physical medicine and rehabilitation 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

The parent of a 17-year-old female enrollee has requested intravenous immune globulin (IVIG) treatment for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that IVIG is indicated and FDA approved for primary immunodeficiency disorders, B-cell chronic lymphocytic leukemia, and immune thrombocytic purpura, and Kawasaki disease. Chronic fatigue syndrome is not an FDA approved indication for IVIG, as there is no convincing evidence in the medical literature to supports its use in this setting. Furthermore, regarding the efficacy of IVIG therapy for chronic enteroviral infection, the only study examining this issue involved B-gammaglobulin deficient patients with chronic meningoencephalitis; IVIG has been tried on a few select cases with variable outcomes. Preliminary literature suggests that oral immunoglobulin therapy may be of value in severe gastrointestinal infections. However, there is no clear indication on how to select the best candidates for this type of therapy (Dattani, et al.). Moreover, based on the evidence provided, this patient does not have an immune deficiency.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that 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 (CT) 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 patients case, the records noted heterogeneously dense breast tissue.  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.  Final Result: Three 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: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested for X-Stop decompression for treatment of his chronic low back pain. Findings:  Three physician reviewers found that X-Stop decompression has been developed in an attempt to identify an alternative treatment to decompressive laminectomy, with or without fusion, in cases where conservative treatment was not sufficient. Early data has shown some favorable results, but some problems have been reported, and a high failure rate has been noted in cases of spinal stenosis complicating degenerative spondylolisthesis. Further study to determine optimal design and clinical indications has been suggested. At this time, a study to clarify these questions is under way, but the results are not yet available. Until additional data is available the efficacy of X-Stop decompression remains unproven.
Appeal type: Medical Necessity
Decision: Overturned

Review of the physical therapy notes document the patient was walking in standing frame initially following his stroke. He received a brace on 9/21/04, at which time he was able to walk with the brace and pickup walker with minimum assistance. On 9/28/04, it was noted the patient was walking with a brace and hemiwalker (assist not recorded). On 11/20/04, the patient was walking with a brace and quad cane up to 50 feet. On 12/7/04, the patient was walking up to 100 feet. It was noted that he was not safe with gait and his family was having problems putting on the brace at home. On the patients last visit, adjustments were made to the brace by his orthotist. A request has been made for continued physical therapy sessions. The Health Plan has denied the request on the basis that further therapy is not medically necessary for this patient.Review of the submitted clinical records indicates the patient was clearly making progress with gains documented. However, as of 12/7/04, the patient and his family were having significant difficulty with applying the brace at home. Furthermore, there was no chance to follow-up after the brace was adjusted because therapy was discontinued. Given that the patients condition is likely to continue to improve additional physical therapy is medically necessary and should be authorized. The Health Plans denial should be overturned. The patient should receive three months of physical therapy with re-evaluation at the end of the three-month period.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old male has requested nebulized Amphotericin B for treatment of his allergic bronchopulmonary aspergillosis (ABPA).  Findings:  Two physician reviewers found that the patient has been diagnosed with allergic bronchopulmonary aspergillosis (ABPA). The patient is also diagnosed with bronchiectasis with progressive cavitary degeneration of the lung, fungal mycetoma, arteriovenous malformation of the lung and recurrent hemoptysis. The patient has attempted trials of prednisone and voriconazole, which were of no benefit. Additionally this treatment is now contraindicated due to the presence of uncontrolled diabetes and liver failure. In this patients case, standard pharmacological treatments utilizing prednisone and voriconazole are now contraindicated given the patients diabetes. Standard therapy with embolization is a first-line therapy in this setting and is typically very effective at controlling hemoptysis. The proposed alternative with nebulized Amphotericin B has been suggested based on the higher tissue concentration with decreased toxicity and it has been noted to be successful as a prophylaxis in immunosuppressed patients with cystic fibrosis with allergic bronchial aspergillosis (Brinson, et al.). Bronchial arterial embolization and pharmacotherapy with nebulized Amphotericin B are not exclusive of each other. All told, it appears that a combination approach consisting of embolization along with nebulized Amphotericin B is likely to be more efficacious for this patient than standard pharmacological therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for the medication HP Acthar gel (Corticotropin Inj Gel 80 U/ML) for treatment of the enrollees ankylosing spondylitis of the cervical region. Findings:  The physician reviewer found that At issue in this case is whether the requested HP Acthar gel (Corticotropin Inj Gel U/ML) is medically necessary for treatment of the enrollees medical condition.This is a case of ankylosing spondylitis with recent flare. Treatment thus far has included Humira, methotrexate, naproxen and Medrol. The request is for Acthar gel. Calhouf and colleagues indicate that compared with placebo, tumor necrosis factor blockers improve disease activity and provide clinically meaningful functional capacity for patients with ankylosing spondylitis. Assessment in SpondyloArthritis International Society (ASAS) guidelines also supports the use of tumor necrosis factor blockers for the treatment of ankylosing spondylitis. In this case, the patient has no history of allergy or contraindication to tumor necrosis factor blockers or other standard therapy. The notes state that there is improvement with Humira. The requested medication, Acthar gel, does not have a Food and Drug Administration approved indication for ankylosing spondylitis. There are no guidelines or recommendations for this medication to be used in a case such as this. The medical records fail to demonstrate that Acthar gel is medically necessary for the treatment of this patient's ankylosing spondylitis. 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 in internal medicine with subspecialty certification in allergy and immunology and rheumatology 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 38-year-old female who is requesting growth hormone therapy. She has a history of variable weight between 150 and 210 pounds over approximately the last five years. She also has a potential diagnosis of hypothyroidism made by an alternative medicinal provider based on a 60-pound weight gain, fatigue, and low temperature. It is not clear if any documenting biochemical tests were performed at the time of the diagnosis. The patient was placed on Armour thyroid in high dose and based on her suppressed TSH has been biochemically hyperthyroid for most of the time since. It should be noted that over 10 years ago the American College of Physicians recommended the removal of Armour thyroid from the prescription medication market due to variable potency and effectiveness.The patient went to see an endocrinologist for her thyroid problems. Though the patients IGF-1 was normal, an arginine GHRH stimulation test was performed. The stimulation test results returned with a barely normal peak GH response. Based upon these results and the patients non-specific symptoms a diagnosis of AGHD was made and treatment with growth hormone injections prescribed. No other tests indicated growth hormone or other pituitary insufficiency. A MRI was normal.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Tobii Dynavox I-110 with Snap + Core First speech-generating device (SGD). The American Speech-Language-Hearing Association (ASHA) notes that communication services and supports should be based on individual communication needs, and should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC). Brady and colleagues report that individuals with disabilities should be able to access functioning AAC and other AT (assistive technology) services and devices at all times. Current medical literature supports the provision of an AAC device for individuals with disabilities who have been evaluated and found capable of using such a device. Morin and colleagues report that the use of high-tech AAC to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. Virbalas and colleagues describe the reduced receptive vocabulary and profound deficit in expressive language in children with Cri-du-Chat syndrome, noting that speech and language therapy, including augmentative communication devices, may enhance effective communication and improve the quality of life of these patients. In this case, the records note that the patient has undergone a thorough evaluation by a speech therapist skilled in the evaluation of children for their suitability for AAC devices. Other, less technologically complex devices have been considered and found to be inadequate for this patient's communication needs. She is not expected to develop oral language  and is exhibiting significant behavioral issues which are probably largely a result of frustration due to her inability to communicate. The patient has adequately demonstrated an ability to use the device, and ongoing speech therapy using the device is planned. Given that current medical literature supports the use of AAC is this clinical setting, and as the requested device enables the patient to communicate her wants and needs, the requested device is medically indicated. Therefore, a Tobii Dynavox I-110 with Snap + Core First SGD 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 neurology with special qualifications 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (CPT 84999 and 83520). The records provided for review document that this patient presented with Crohns disease while on treatment with vedolizumab. The patient underwent testing with Prometheus Biosciences Anser VDZ, which revealed detectable serum vedolizumab and undetectable antibodies to vedolizumab. Although therapeutic drug monitoring has the potential to improve the outcome parameters of vedolizumab treated patients with Crohns disease, the peer-reviewed medical literature has not demonstrated a clinically meaningful antibody level for vedolizumab. In addition, immunogenicity to vedolizumab is found approximately fewer than 1% of patients with persistently positive anti-vedolizumab antibodies. The low immunogenicity of vedolizumab limits the utility of determining vedolizumab antibody levels to direct treatment planning. For these reasons, the laboratory testing (CPT 84999 and 83520) not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the laboratory testing (CPT 84999 and 83520) 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 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: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for a Positron Emission Tomography (PET) scan.The submitted documentation does not support that the requested services are medically necessary. Small cervical lymph nodes are commonly detected on CT scans. In addition, surgical oncologists and radiologists should be aware of reactive lymphadenitis in interpreting postoperative restaging FDG PET/CT scan when FDG avid lymphadenopathy is only seen in the lymphatic draining location from surgical site. In this case, the patient presented with a common complaint. She was appropriately evaluated with a CT scan which did not demonstrate substantial adenopathy. The palpable nodule corresponded in location to a tiny lymph node which was subsequently biopsied with a benign result. The patients history notes that she had a prior biopsy of what was apparently a benign thyroid nodule. Under these circumstances, a PET scan is not warranted, as there is no history of a prior malignancy, and there were no signs of diffuse adenopathy detected on physical examination. Accordingly, the requested Positron Emission Tomography (PET) scan is not medically necessary to treat the patients medical condition.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 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.