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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Afirma Gene Expression Classifier test evaluation of her thyroid nodule.  Findings:  Three physician reviewers found that molecular testing has been proposed by the American Thyroid Association (ATA) as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. The ATA guidelines state For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the patient had multiple biopsies with indeterminate results. Thus, the submission of the specimen to Afirma gene expression classifier was appropriate. A benign result would have prevented unnecessary surgery in this patient. The rate of unnecessary surgeries and associated morbidity has decreased with the use of molecular testing. In this case the decision to refer the biopsy specimen to Afirma testing was appropriate. All told, the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Two physician reviewers are board certified in endocrinology and metabolism and are actively practicing. One physician reviewer is board certified in oncology and is 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: Overturned

The parent of a two-year-old male has requested coverage for speech therapy for treatment of his developmental delay not otherwise specified and speech delay.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability (Nelson, et al.). According to a Cochrane Database meta-analysis, speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties typically produce positive outcomes. Early intervention can promote normalization of speech development and normal acquisition of skills for some children (Bernhardt and Major). Further, in a recent review of therapeutic intervention for children with speech and language delay, McLaughlin concluded that there is good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. This patient is a two-year-old with a moderate expressive language delay, as well as delays in other areas of development. His language delay significantly impairs his ability to communicate effectively and function socially. In accordance with the peer-reviewed medical literature, the requested speech therapy is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male who was seen by his physician on 9/28/04 because of non-traumatic headache. Though the progress notes from that visit discuss the patients symptoms, there is no documentation of a physical or neurological exam. The patients physician ordered a CT scan of the head. The Health Plan indicates a head CT is not medically necessary for evaluation of the patients medical condition. According to the American College of Radiology Appropriateness Criteria, screening patients with isolated, non-traumatic headache by means of CT or MRI is not warranted. There are exceptions to this statement including patients with a history of cancer or HIV, older patients (over age 50) or patients with thunderclap headaches or headaches radiating to the neck. This patient does not meet any of these exceptions. In addition, there is no documentation of any neurological findings. Furthermore, it does not appear the patient has received any conservative therapies. Based upon the information provided, there is no medical indication for a CT scan of the head. Therefore, I have determined that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Adcirca for treatment of her medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The patient has primary pulmonary hypertension as the wedge pressure was normal and the pulmonary artery pressure was very high. The current medical evidence supports Adcirca in this clinical setting.  Combination therapy with the addition of Adcirca is a standard of care in this patients case.  All told, the requested medication Adcirca is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: Urgent Care
Decision: Upheld

A 19-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that a patient must be suffering from the sudden onset of symptoms of such severity that a prudent layperson would believe the lack of immediate medical attention to result in serious jeopardy to his health. Although this patient did report severe pain, the pain was not acute in onset. He had sustained an injury to his ankle. Further, the patient did not require any pain control in the emergency department. While his symptoms warranted medical evaluation, this care did not need to be provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old male who was born prematurely at 23.4 weeks. In the neonatal period he developed a bilateral grade III intraventricular hemorrhage with resulting hydrocephalus. He underwent shunt placement. The patient was diagnosed with cerebral palsy at the age of 18 months. Treatment has included physical therapy and Botox injections for lower extremity spasticity. The patients provider has recommended the patient undergo a selective dorsal rhizotomy with a single laminectomy at L1. The Health Plan has denied authorization for the proposed procedure indicating there is insufficient evidence demonstrating a difference in outcomes between a rhizotomy with single level laminectomy and a rhizotomy with double level laminectomy. A rhizotomy with a single level laminectomy has been recommended on the basis it is superior to a rhizotomy with a multiple level laminectomy. The basis for this contention is two recent articles, one by D. Speigel and the other by M. Johnson. The articles discuss spinal deformity after selective dorsal rhizotomy. Though the results indicate there was an increase in scoliosis, spondylosis, and spondylolisthesis, the Speigel article reports only one patient required a second surgical procedure and the Johnson article reports none of the patients required additional surgery. Review of the relevant medical literature does not suggest a rhizotomy with a single level laminectomy will be superior to a rhizotomy with a multiple level laminectomy for this patient. The evidence does not demonstrate a significant difference between an appropriate surgeon performing a single level laminectomy versus a multiple level laminectomy. Because there is inadequate evidence demonstrating a rhizotomy with a single level laminectomy will provide the patient with greater benefit, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for aquatic therapy. Aquatic therapy is a form of exercise therapy which minimizes the effect of gravity and is beneficial for patients with morbid obesity and osteoarthritis who would otherwise not be able to exercise due to pain and excessive body weight. Researchers concluded that aquatic-based exercise generate a different exercise outcome and appear to provide an alternative option for older aged adults, allowing these tasks to be performed in a manner that is not possible on land. Land based physical therapy is difficult for morbidly obese patients. As such, the requested aquatic therapy 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, because of the myriad benefits associated with successful HCV treatment, patients should be treated with antiviral therapy with the goal of achieving a sustained virologic response (SVR), preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of SVR. In a long-term follow-up study, 820 patients with Metavir stage F0 or F1 fibrosis confirmed by biopsy were followed for up to 20 years. The 15-year survival rate was statistically significantly better for those who experienced an SVR than for those whose treatment had failed or for those who remained untreated. Therefore, based on the documentation submitted for review and national guidelines Harvoni for eight weeks is medically for treatment of the patients medical condition. Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

A 49-year-old female enrollee has requested authorization and coverage for an MRI of the right knee for the treatment of knee pain. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested MRI is medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 9-year-old male enrollee has requested 24 hours of direct applied behavioral analysis (ABA) therapy in the home and the community (including staff and family training) for treatment of the enrollee's autism. Findings:  The physician reviewer found that in the medical literature, Foxx and colleagues discussed the positive impact ABA therapy has been shown to have on young patients with ASD. The authors noted that ABA utilizes methods derived from scientifically established principles of behavior and that intensive treatment is needed, usually at least 20 hours per week. Further, the National Institute of Mental Health also acknowledges that ABA has become widely accepted as an effective treatment. Moreover, Granpeesheh and colleagues article states that ABA treatment programs are supported by scientific evidence and are recommended for patients with autism. Thus, the documentation supports the medical necessity for the 24 hours per week of ABA services provided, in addition to the request for authorization for future services for management of this patients delays secondary to ASD.
Appeal type: Medical Necessity
Decision: Overturned

HOLD    HOLD      HOLD            HOLD   The patient is a 38-year-old woman with severe maxillary alveolar atrophy. She has been edentulous in the maxilla since the age of 21 and wears a full maxillary denture prosthesis, which occludes with natural dentition in the mandible. The maxillary denture now has poor retention and poor stability because of atrophy of the supporting maxillary alveolar process resulting in discomfort and inability to masticate a wide variety of foods. The patients treating providers have recommended augmentation of the maxillary alveolar bone with bone grafting in the floor of the maxillary sinuses to allow eventual placement of endosseous dental implants. The goals of the recommended treatment are to provide retention and stability to an upper denture prosthesis, stem further resorption of the maxillary alveolar process, and restore normal masticatory function. The Health Plan has denied authorization for the requested procedures on the basis that the procedures were not covered benefits.The recommended maxillary bone grafting and placement of dental implants are medically necessary for treatment of the patients medical condition. The patients described bone atrophy is an abnormal structure of the body. It is caused by chronic trauma to the maxillary alveolar process. Bone grafting and placement of dental implants are needed to improve function and to create a normal appearance to the extent possible. The requested procedures have been sought in order to treat a condition directly affecting the upper jawbone. Failure to authorize these procedures in this case would result in a failure to provide medically necessary health care services to this patient. Therefore, I have determined that the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested 12 transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the submitted documentation fails to establish that the services at issue were likely to have been superior over other available treatment alternatives.  She has a history of alcohol use and it is not clear what role this has played in inhibiting recovery from depression. There is evidence that the patient improved during the time period under review.  However, it is not clear whether this improvement was due to the transcranial magnetic stimulation or other variables. Furthermore, it is not clear if the patient experienced a sustained benefit.  As noted by Martin and colleagues, there is insufficient data regarding the efficacy of transcranial magnetic stimulation to warrant its use in standard practice. The American Psychiatric Association guidelines indicate that electroconvulsive therapy is the most effective treatment for depression.  All told, the 12 transcranial magnetic stimulation treatments provided during the said time frame were not likely to have been of greater benefit than other treatment modalities in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested authorization and coverage for a bilateral breast MRI. The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollee, who has a history of atypical ductal hyperplasia. Findings:  Two physician reviewers found that this patient has atypical ductal hyperplasia.  An MRI of the breasts was performed.  The provider noted several enhancing small lesions.  The provider noted that this was likely benign, although a follow-up breast MRI in six months was recommended to ensure stability.  The patient has requested authorization and coverage for a bilateral breast MRI.  The Health Plan has denied this request and reported that the requested diagnostic procedure is investigational in this clinical situation.  The patient has appealed this denial.  In this patients case, the requested bilateral breast MRI is likely to be superior over other methods of evaluating this patient.  She has been diagnosed with atypical ductal hyperplasia.  The MRI report described findings requiring surveillance to ensure a benign etiology.  These findings are best evaluated with the requested bilateral breast MRI.  Since the abnormal findings were noted using breast MRI, a repeat MRI is the imaging of choice for follow-up evaluation.  The current medical evidence supports the requested diagnostic procedure in this patients case.  All told, the requested bilateral breast MRI is likely to be more efficacious than other tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee, with a history of chronic allergic asthma since childhood and continuing exacerbations, has requested authorization for Xolair.  Findings:  The physician reviewer found that the patient has been followed for a diagnosis of severe allergic asthma that appears poorly controlled despite optimal medical treatment. The patient has received optimal medical care, has adhered to treatment plans, and her condition has failed to respond adequately. The patients quality of life is severely impaired by her condition. Furthermore, there is concern regarding the continued use of steroids.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for 56 hours per week (eight hours per day) of home skilled nursing services. Findings:  The physician reviewer found that patient presents with congenital myasthenia gravis, hypoxic ischemic encephalopathy, severe dysphagia, and ventricular septal defect. As noted in the medical literature, the congenital myasthenic syndromes include a group of diverse genetic disorders that result in dysfunctional neuromuscular junction transmission. Clinical manifestations include weakness of the ocular and other cranial muscles, fatiguability on exertion, limb weakness, and generalized weakness. Based on the available documentation, this patient requires supervision due to safety and intermittent physical assistance for some tasks that can be provided by a caregiver or a trained aide such as placing him on and off of his ventilator, respiratory tract hygiene, and gastrostomy tube feeding/medication administration. His skilled nursing needs including caregiver training, tracheostomy changes, changes in his ventilator settings, and gastrostomy tube changes can be met with intermittent home nursing visits. The patient is placed onto his ventilator via his tracheostomy around midnight, which is placed on pressure control mode without supplemental oxygen, and he stays on this until about 5:30 in the morning. Occasionally, he receives interventions for respiratory tract hygiene. His tracheostomy tube is changed once a week. He is also receiving feedings, fluid boluses and medications through his gastrostomy tube chronically, due to his severe dysphagia with oral intake restrictions. His respiratory and dysphagia conditions are chronic and stable. The available records do not support the medical necessity of eight hours per day of skilled nursing services for this patient. All told, the 56 hours per week (eight hours per day) of home skilled nursing services were not and are 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested allergy testing for evaluation of her medical condition.  Findings:  The physician reviewer found that the medical records fail to indicate any diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease and the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. As such, IgG food testing is not the standard of care and is not medically necessary for evaluation of the patients medical condition.  However, IgE testing may be helpful in treating this patient. About 50% of children and 35% of adults are sensitive to food or aeroallergens (Schafer). Infants and young children with atopic dermatitis are more commonly sensitized to foods, such as wheat and egg which are the most common (Schafer). Adults and older children are more commonly sensitized to aeroallergens, especially dust mites (Ponyai, et al). In this case, the aeroallergen testing is within guidelines by the American Academy of Allergy, Asthma and Immunology practice parameters for allergy testing and is helpful in atopic dermatitis in adults (Bernstein, et al). As such, the IgE testing for aeroallergens was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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.