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 for evaluation of her medical condition.  Findings:  Three physician reviewers found that Afirma gene expression classifier testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presented with an enlarging thyroid nodule. Cytopathology report noted Hurthle cell lesion, falling under the category of follicular lesion of undetermined significance (FLUS). The risk of malignancy is 5-15% in these lesions (Cibas, et al). According to recent guidelines by the American Thyroid Association For nodules with [atypia 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, molecular testing was consistent with a benign lesion, and a repeat biopsy or hemithyroidectomy was not necessary. Therefore, the requested services prevented the patient from an unnecessary procedure or surgery and their risks. Final Result: Three reviewers determined that the testing 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 reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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

The parent of a 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that there is no indication the patient had the standard recommended treatment for ADHD and ODD or that he and his parents had intensive family therapy prior to his residential treatment admission. The patient was not suicidal or homicidal nor was there evidence of a thought disorder at the time of his residential treatment admission. There was no evidence of self-destructive behaviors, psychotic behaviors or substance abuse problems that would suggest the residential treatment admission was medically appropriate for the primary diagnoses of ADHD and ODD.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested an increase in Levitra to 12 tablets per month for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that this patient had difficulty with erections prior to surgery for prostate cancer (venous leak). This is generally nonresponsive to vasoactive medications. The patients request for 12 tablets of Levitra per month is not medically indicated. The standard of six tablets of Levitra per month would be adequate coverage for a patient with organic impotency.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Vimpat 900 mg per day for treatment of the enrollees partial complex seizures.  Findings: The physician reviewer found that Vimpat is an anti-seizure medication that is commonly utilized to treat patients with epilepsy. However, according to the manufacturer, the maximum daily dose should not exceed 400 mg per day. Specifically, the manufacturer stated that adverse events have been observed after supratherapeutic doses were administered. These events included cardiac arrhythmias, status epilepticus, convulsions and increased seizure frequency and duration. The manufacturer further reported that in one case, after receiving Vimpat 900 mg/day for 23 days, the patient experienced increased seizure duration and frequency. The maximum recommended daily dose of Vimpat in patients with partial onset seizures is 400 mg and higher doses are not recommended per the manufacturer guidelines. In this case, a 900 mg per day dose as requested by the patient is not medically indicated. A dose of 900 mg per day may expose the patient to a very high risk of cardiac problems and higher risk of seizures. The requested medication dosage is unsafe and not recommended by the manufacturer and the current medical literature. For these reasons, the requested Vimpat for 900 mg per day for 30 days is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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 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

The parents of a three-year-old male with a history of developmental speech apraxia are requesting reimbursement and prospective authorization and coverage of speech therapy.Reviewers Findings:  The reviewing physician found that therapy for the treatment of developmental speech apraxia would typically fall under the auspices of the school system through an Individual Education Plan.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested  once weekly occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is often a useful adjunct to interventions for autism spectrum disorders. In this case, although the patient has high functioning autism he is deficient in fine and gross motor skills and sensory processing. His deficiencies are likely to improve with the proposed course of once weekly occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that Residential treatment center services provided on 2/7/17 were medically necessary for treatment of the patients behavioral health condition, but not thereafter. The patients blood pressure was low, however there are no medical records addressing this issue. A nursing note documents that the patient was offered Gatorade for dehydration and to raise blood pressure. Other than that episode, the patients vital signs on the remaining days were stable. According to the documentation submitted for review, the patient was not a danger to self or others. The patient was cognitively intact and able to care for self. There were no emotional, behavioral, cognitive, or impulsive symptoms that would support the residential treatment level of care  forward. The patient was psychiatrically stable. As such, the residential treatment center services provided on the date of dispute were medically necessary, however as of the next day, the patient could have been treated at a lower level of care.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine 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 the Life Vest wearable cardioverter defibrillator (WCD) for treatment of the enrollees ST elevation myocardial infarction (STEMI) involving left anterior descending (LAD) coronary artery, atrial flutter, and acute respiratory failure. Findings:  Two physician reviewers found that based on the records provided, the patient presented with severe left ventricular dysfunction soon after coronary stenting for acute myocardial infarction. Cardiac arrest in the immediate acute infarction period generally does not increase risk of subsequent cardiac arrest. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as recurrent sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest in the post infarction period. Placement of a prophylactic defibrillator is not recommended until a period of time, approximately 90 days has elapsed, when continued left ventricular dysfunction demonstrated by an ejection fraction of 35% or less, is documented to persist despite of appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. All told, the Life Vest WCD at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for removal of a benign nevus. Based on review of the medical records, this patient has a left hand dorsal 4 x 5 cm melanocytic nevus. The nevus was determined to be a benign non-cancerous lesion on biopsy. There are no reported functional issues associated with the lesion. Thus, the removal of the benign nevus is not supported as medically necessary. In addition, the condition is not an abnormal structure of the body. Benign nevi are a common finding on the skin. Based on the available documentation, the proposed surgery would not improve function or provide a more than minimal improvement in the appearance of the patient. All told, the requested removal of a benign nevus is not medically necessary or reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the nerve testing (autonomic testing) performed for evaluation of the enrollees small fiber neuropathy symptoms. Findings:  The 3 physician reviewers found that in this case, the patient was under evaluation for multiple symptoms that suggested neuropathy. Small fiber neuropathy can be difficult to diagnose as clinical testing and EMG may be normal. Skin biopsy for small fibers may be helpful, but many patients have other associated symptoms that may indicate involvement of small autonomic fibers which may associated with acroparesthesias (tingling in the hands and feet), abnormal tearing, gastroparesis, constipation, orthostatic hypotension, loss of cardiac beat to best variability, and abnormal pupillary responses. This condition, especially when there is autonomic involvement may be associated with a paraneoplastic syndrome in which case an occult cancer may be found, or autoimmune disorders. Autonomic testing has been relatively mainstream for decades and is supported in the peer reviewed literature. Based on the clinical documentation submitted for review and the support in the peer-reviewed literature, the nerve testing (autonomic testing) performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 3 reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by two associations, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. These guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested shoe inserts for treatment of her plantar fasciitis.  Findings:  The physician reviewer found that per the submitted documentation, the prescribed custom orthotics (shoe inserts) to treat this patients heel pain are medically necessary. Custom tri-planar orthotics (shoe inserts) have been used to treat plantar fasciitis for many years. Studies have shown that the use of orthotics is considered one of the mainstays of plantar fasciitis treatment and the standard of care for this ailment. Medicare guidelines state that a device can be considered medically necessary if it is deemed to be safe and effective, appropriate for the patients condition, not mainly for the convenience of the physician or patient. The medical information enclosed in this case documents that the patient has been treated with over-the-counter orthotics, local steroid injections to symptomatic heel, stretching, and icing. In this clinical setting, the next course of treatment would be custom orthotics.  All told, the requested shoe inserts are medically indicated 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensity modulated radiotherapy. The submitted records do not support the use of intensity modulated radiotherapy technique in the treatment of this patients bone metastases. The standard treatment is with three-dimensional conformal radiation therapy. Intensity modulated radiotherapy is indicated when patients are undergoing re-irradiation to the same site in the palliative setting. However, this patient has not undergone prior radiation to the spine or chest. Currently, researchers have not established that treatment with intensity modulated technique offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for uncomplicated bone metastases. Thus, intensity modulated radiotherapy was not medically necessary for the treatment of this patient. 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 radiation 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: The patient has requested authorization and coverage for referral to an eye movement desensitization and reprocessing (EMDR) specialist. Findings:  The physician reviewer found that EMDR is specifically indicated for the treatment of patients with post-traumatic stress disorder (PTSD). Based on the available documentation, this patients presentation does not support a diagnosis of PTSD. In addition, there is a lack of documentation of symptoms consistent with PTSD. Bereavement is distressing, particularly that after a childs death. However, this is not considered an exposure to an actual or threatened death, injury or violence, which is required for a PTSD diagnosis per the American Psychiatric Association (APA). Tol and colleagues noted that, For adults, adolescents, and children with PTSD, recommended treatments include individual or group CBT-T [cognitive behavior therapy with a trauma focus], eye movement desensitization reprocessing (EMDR) and, in adults, stress management. The patient would benefit from psychological support including grief support group therapy to aid in grieving the loss of her son. However, there is a lack of indication for EMDR therapy. The records do not report that EMDR has been recommended by any of the patients treatment providers. Moreover, the requested referral to a specialist in EMDR is not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested referral to an EMDR specialist is not medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablets. According to Gatta and Scarpignato, rifaximin (brand name Xifaxan) treatment is effective and safe for the treatment of small intestinal bacterial overgrowth (SIBO).  Barkin and colleagues report that rifaximin is the most commonly prescribed antibiotic regimen for SIBO therapy as a highly effective therapy in providing symptom relief from the effects of SIBO. Rao and Bhagatwala report that rifaximin is shown to be effective against SIBO and well-tolerated. In this case, given that the patient has symptoms and testing consistent with small intestinal bacterial overgrowth, the requested medication is medically indicated. Therefore, Xifaxan 550 mg tablets are medically necessary 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 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.