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

The parent of a five-year-old male enrollee has requested vision therapy for the treatment of the enrollees strabismus. Findings:  The physician reviewer found that strabismic patients exhibiting esotropia with many associated conditions (likely anomalous correspondence, no fusion  similar to this patient) tend to be the most difficult to successfully treat with vision therapy. These patients require extremely aggressive programs of vision therapy, none of which are typically administered to a five-year-old. In general, the treatment period tends to be longer for long standing, infantile esotropia than other types of strabismus. (Berard, et al.). However, vision therapy is appropriate and medically necessary for treatment of the patients oculomotor dysfunction and accommodative infacility. The patient should receive 12-24 sessions depending on his response to the therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested ceftriaxone sodium injections for treatment of his medical condition.  Findings:  Three physician reviewers found that the current medical evidence does not support the requested services in this clinical setting.  Late Lyme disease is typically associated with intermittent or persistent arthritis involving one or a few large joints, and/or certain rare neurologic problems, primarily a subtle encephalopathy or polyneuropathy.  Arthritis may be the presenting manifestation of the disease.  The recommended initial treatment regimen is oral doxycycline or oral amoxicillin.  Approximately 90 percent of patients with arthritis respond to a single course of oral therapy.  In patients whose arthritis has improved, but not completely resolved, after one month of oral therapy, a second course of the same antibiotic is suggested.  In contrast, patients who have had little or no improvement after the initial course should be treated with intravenous therapy.  In this case, the documentation does not support that the patient has failed first-line therapy with an oral antibiotic. The documentation does not support that the patient had any neurologic or cardiac involvement.  Therefore, the requested ceftriaxone sodium injections are not likely to be of greater benefit than other treatment options.  Final Result:  Three reviewers determined 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:   One reviewer is board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing.   Two reviewers are board certified in internal medicine and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested coverage for laser endovenous laser treatment (EVLT). The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees varicose veins.  Findings:  The physician reviewer found that based on review of the available records, the patients surgeon has requested sclerotherapy and EVLT for treatment of recurrent branch vein reflux. The Health Plan has approved the sclerotherapy which generally includes the use of ultrasound to guide needle placement as a component of care. However, according to the Duplex, the GSV is absent due to successful previous ablation. Thus, the records do not demonstrate any evidence of a unique clinical feature to warrant the requested EVLT as requested in this case. For these reasons, the requested procedure has not been shown to be medically necessary for treatment of the patients medical condition and therefore the denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for speech therapy twice a week. The records provided for review document that this patient demonstrated inadequate progress in her speech and language skills during the last evaluation period, as her therapy transitioned to telehealth due to the pandemic. The patient has regressed in her receptive language but has made some progress in expressive language. She has also made progress in articulation. As noted in the medical literature, children with autism spectrum disorder frequently have difficulty attending to telehealth therapy, and loss of skills during the pandemic has been a significant issue for children with developmental disabilities, especially autism spectrum disorder. Manning and colleagues described stress around therapeutic service disruption in families of children with autism spectrum disorder due to the pandemic. The authors noted that the provision of speech therapy to children with autism spectrum disorder is considered the standard of care. Baumer and Spence reported that the treatment of patients with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech and language, occupational, and physical therapies. Moreover, the American Academy of Pediatrics (AAP) recommends speech therapy as a standard of care, stating that Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder (Hyman, et al.). Since this patient met one-third of her goals and made moderate progress towards her other two goals even with her transition to telehealth, she should continue to receive speech therapy services to address her remaining goals and prevent regression of newly acquired skills. The requested services are in accordance with the generally accepted standards of mental health care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, the requested speech therapy twice a week 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a speech therapy evaluation. This patient is demonstrating some challenges with learning that could be related to ADHD or dyslexia. However, speech therapy is not the appropriate approach to identify the patients current difficulties. Previous testing suggested significant problems with articulation and intelligibility. Therefore, the patient requires further cognitive and achievement testing which can be performed through the school or with a psychologist. Based on the previous testing, she does not need a speech and language evaluation. Thus, the requested speech therapy evaluation is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested follow-up visits with a reproductive endocrinologist for treatment of her polycystic ovarian syndrome and infertility.  Findings:  The physician reviewer found that based on review of the available records, the requested services are medically necessary for treatment of this patients medical condition. The patient has a documented history of infertility since her initial visit with her provider in 2011. She currently has been infertile for five years. A semen analysis in 2011 was abnormal revealing a male factor, and the patient has ovulatory factor with a diagnosis of PCOS with oligo-ovulation. The medical records suggest that infertility services are recommended for the patient. Infertility evaluation services, which include the evaluation of this couple for male and female infertility, are within the standard of care. Therefore, the requested services are medically necessary for management of this patients medical condition and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a five-year-old male with speech delay noted as early as 18 months by his parents. He has received extensive therapy from July 2004 to March 2005 and his parents are also seeking authorization for continued speech therapy three days a week. At issue in this case is whether the therapy the patient received from July 2004 to March 2005 was medically necessary and whether continued therapy three days a week is necessary.The patient has been evaluated by a number of speech therapists. The evaluations are consistent and document the patients speech delay. The frequency of speech therapy is not well established in the literature. There is no evidence supporting the need for speech therapy three times a week. Furthermore, the patient has a common diagnosis for which speech therapy once a week has been proven to be effective. Although this patient has benefited from therapy, there is no evidence he would have benefited less from less frequent therapy or that he benefited more from more frequent therapy. Therefore, although speech therapy was and is medically indicated and necessary for this patient, speech therapy multiple times a week was not and is not medically necessary.Based upon the information submitted, I have determined 24 speech therapy sessions were medically necessary for treatment of the patients medical condition from July 2004 to March 2005. In addition, I have determined speech therapy once a week from 4/1/05 to 6/1/05 is medically necessary. After 6/1/05, the patient should be re-evaluated to determine whether continued therapy is medically necessary. Therefore, I have determined the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the CHG exome sequence analysis for evaluation of the enrollees sensorimotor neuropathy.Findings: All three physician reviewers found that while genetic testing is not indicated for all patients with neuropathies, it is reasonable for well selected patients. In this case, the patient has a progressive neuropathy of unknown etiology. The patient has some clinical features that may suggest a non-hereditary etiology including an elevated CSF protein and gammopathy. It is therefore important to determine the specific etiology of the neuropathy as a hereditary neuropathy is managed differently from an inflammatory neuropathy or neuropathy due to a gammopathy. Genetic testing is an appropriate method to determine if the patient has a hereditary etiology. Therefore, the request for CHG exome sequence analysis is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three physician reviewers determined that the requested testing is 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 neurology 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 67-year-old male enrollee has requested acupuncture for treatment of his allergies and high blood pressure.  Findings:  The physician reviewer found that the Tufts Medicine documentation notes that acupuncture has been used to treat hypertension in clinical practice with very few reported adverse effects. However, to date, the effectiveness of this treatment has not been explored adequately in published studies. Although the results of some randomized controlled trials demonstrate some benefits for acupuncture for managing hypertension, the results must be treated with caution because of serious methodological limitations. Specifically, sample sizes have been small and generally inadequate, randomization and the use of controls are rare and poorly characterized, interventions often do not reflect traditional clinical practice and the period of follow-up has been inadequate or unspecified. Thus, acupuncture is not considered a standard of care for the treatment of hypertension. Per Goroll and Mulley, immunotherapy is a standard of care for allergic rhinitis in patients who have failed medical therapy with antihistamines alone or in combination with intranasal steroids and/or leukotriene inhibitors. Currently, there are no peer-reviewed studies to support the efficacy of acupuncture to treat allergic rhinitis. The use of acupuncture is not the standard of care in this setting and there is inadequate evidence documenting its benefits for patients with allergic rhinitis. Thus, acupuncture is not clinically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. These medications are Food and Drug Administration (FDA) approved for the treatment of chronic hepatitis C (CHC) genotype 1 infection in adults. In addition, Harvoni carries the highest recommendation of the American Association for the Study of Liver Diseases and Infectious Diseases Society of America (Rating: Class I, Level A ) for treatment of HCV patients with this patients characteristics. Once-daily ledipasvir-sofosbuvir  (Harvoni) with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. (Afdhal et al). In patients, similar to this patient, with viral loads less than 6 million IU/ml, ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis (Kowdley et al). Further, there was no additional benefit with extension of the duration of treatment (Kowdley et al). Therefore, although Harvoni is medically appropriate in this setting, the requested duration of 12 weeks is not medically necessary for treatment of the patients medical condition.  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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a seven-year-old male enrollee has requested cognitive therapy services for the treatment of the enrollees autism. Findings:  Two physician reviewers found that this patient is described as having high-functioning autism with significant language and socialization deficits. He was placed in a special intervention program by the age of three.  A component of the services at issue is music therapy, which is recognized as an accepted form of therapy for autistic children. The text by Berger is a standard source for information of the theories, history and applications for treating autistic children and supports the use of music therapy. Stahmer and colleagues also mention music therapy as a standard community treatment for autistic children. With regard to the cognitive behavior component of the therapy, while at this patients age it may be somewhat difficult for him to intellectually understand his disability, cognitive behavior therapy is often utilized in autistic patients. Hormer and colleagues consider a form of cognitive behavior treatment in their paper.  Furthermore, as Stahmer and colleagues point out in their paper, multiple approaches are necessary, as few specific treatments have been established as efficacious for some children with autism in research settings. Truly double-blinded studies in autism with follow-up until adulthood are lacking. Given the absence of such studies, it is acceptable to use expert opinion, which does accept cognitive therapy as efficacious in the treatment of autistic children.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Byetta 5 mcg pen-injectors. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes. A review of the records indicates the enrollee is diagnosed with type 2 diabetes. The enrollee has stated that she has been taking Byetta for type 2 diabetes for 9 years. The submitted documentation does not support that the requested medication is medically necessary. The requested medication, Byetta, is a GLP-1 agonist and has a similar mechanism of action as others in its class such as Trulicity or Victoza. GLP-1 agonists like Byetta are FDA approved for use in type 2 diabetes. Head-to-head clinical studies by Trujillo and Madsbad and colleagues have demonstrated that all GLP-1 agents are effective therapeutic options at reducing A1C in subjects with type 2 diabetes. In this case, there is no indication why the patient cannot use other available GLP-1 agents such as Trulicity or Victoza, which have a similar therapeutic profile, nor is there documentation that the patient has tried and failed other such medications. Furthermore, medical literature does not support that Byetta is superior to other available GLP-1 agonists. Under these circumstances, Byetta is not medically necessary for treatment of the enrollees 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 internal medicine, with subspecialty in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 20-year-old female enrollee has requested for emergency services were not required on an emergent basis. Findings:  The physician reviewer found that patient had been suffering from a cough for several days. She denied any pain at the time of her visit. She denied shortness of breath or vomiting. Her symptoms had not suddenly changed or worsened. The records document that the patient was well-appearing and in no distress. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A sixty-three year-old male with coronary artery disease, post stents, is requesting a CT angiography.  The patient has non-exertional chest pain and arm tingling.Reviewers Findings:The reviewing physician found that a CT angiography is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorder. Consistent with this support, the requested TMS therapy is medically necessary for treatment of the patients major depressive disorder.