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

The parent of a 2-year-old female enrollee has requested speech therapy at a frequency of twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. As such, the speech therapy services should be covered since the said date with authorization for future services as medically necessary for her care. The patient should be re-evaluated in six months to assess her progress and ascertain whether additional therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 10-year-old female with global developmental delay. Specifically, the patient has had significant delay in activities of daily living including dressing and brushing teeth. She also has difficulty with fine motor skills. She received occupational therapy in the first half of 2003 and then went to China to try alternative treatment. The patients provider is now requesting occupational therapy to address the patients self-help skills and fine motor skills. The Health Plan indicates additional occupational therapy is not medically necessary.In reviewing the previous occupational therapy summary from January to March 2003, it does not appear the patient was making functional gains. The goals provided in the most recent evaluation are similar to the goals from 2003 reflecting a lack of progress since that time. Therefore, functional progress would not be anticipated in an appropriate amount of time. Progress will likely come through significant repetition, which can be accomplished through community-based services. There is no clinical indication for additional occupational therapy at this time. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested artificial disc replacement surgery for treatment of his cervical stenosis.   Findings:  Three physician reviewers found that artificial disc replacement with ProDisc-C is approved for one-level replacement and not in conjunction with a fusion as proposed for this patient. The adjacent segment concern at C4-5 occurs in less than 15% of these patients. Additionally, there are no large, scientific studies showing the long-term safety and effectiveness of ProDisc-C. Murrey and colleagues report only involved a two-year study and the FDAs approval of the device requires a study with long-term follow up, which is still underway. Thus, the efficacy of cervical artificial disc replacement has not been sufficiently established at this time. Further studies involving more than two-years follow up are needed to determine the safety and effectiveness of the procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, a mass found in the right breast was a new or changing development since the prior studies. In this circumstance, tomosynthesis is indicated to better distinguish the mass in terms of its contours and margins. This is especially true when the mass is only detected on one view. For the reasons provided, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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 diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers compared to standard mammography alone. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 60-year old male who was diagnosed with coronary artery disease. He also has a history of chronic obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco use, laryngeal cancer, and thyroid cancer. Findings:  The physician reviewer found that a Persantine nuclear stress test revealed no evidence of myocardial ischemia. In a letter, the provider noted that the patient underwent percutaneous transluminal coronary angioplasty and stenting to the left anterior descending artery in 2013. The patient endorsed sharp and stabbing chest pain not consistently relieved with nitroglycerin. There was no documentation the patient had been treated with a calcium channel blocker or long-acting nitrate. The patient has requested authorization and coverage for ranolazine. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether ranolazine is medically necessary for the treatment of the patients medical condition. Beta blockers should be prescribed as initial therapy for relief of symptoms in patients with stable ischemic heart disease (SIHD). Calcium channel blockers or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects in patients with SIHD. Per the 2012 article by Fihn and colleagues, calcium channel blockers or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful in patients with SIHD. Although this patient has been diagnosed with coronary artery disease, his chest discomfort symptoms do not present as anginal in nature. There is no evidence of ischemia on stress testing, indicating that his symptoms are non-anginal. There is no documented angina or coronary ischemia. Furthermore, there is no documented trial or intolerance to other more standard anti-anginal medications, such as calcium channel blockers and long-acting nitrates. The medical evidence does not support the requested medication in this clinical setting. Therefore, ranolazine is not medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza 3-PAK for treatment of her uncontrolled diabetes mellitus. Findings:  The physician reviewer found that Victoza is a glucagon-like peptide-1 receptor analog (GLP-1 RA). Glucagon-like peptide-1 (GLP-1) based therapies affect glucose control through several mechanisms, including enhancement of glucose dependent insulin secretion, slowed gastric emptying, and reduction of postprandial glucagon and of food intake. These agents do not usually cause hypoglycemia in the absence of therapies that otherwise cause hypoglycemia. Victoza is indicated in the treatment of diabetes mellitus and obesity. The recent American Diabetes Association (ADA) standards of care for the treatment of diabetes recommend that a patient-centered approach should be used to guide the choice of pharmacologic agents. This patient had a regimen that worked very well for her as demonstrated by her ability to lose weight, control her diabetes and blood pressure to goals, and allowed her to discontinue insulin and antihypertensive therapy. The patient completed an adequate trial of Tanzeum, without benefit.  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 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: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested gene testing (GeneSightRx)for treatment of her behavioral health conditions.  Findings:  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The efficacy of gene testing to guide psychotropic medication prescribing remains unproven. Although there is some evidence to suggest that such testing may offer promise for the future (Hall-Flavin et al), there is insufficient evidence that gene testing guided psychotropic prescribing is likely to be more beneficial than traditional management of psychotropic medications. Moreover, there is a lack of evidence presented in the form of multicenter long term trials that have been replicated over long periods of time. According to Hall-Flavin and colleagues, more research is needed to fully demonstrate the benefit of these newly developed strategies to guide treatment. As such, gene testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Leggett and colleagues found that the available data on the use of repetitive TMS (rTMS) for adults with treatment resistant depression suggests that rTMS is approximately twice as effective as a sham procedure. Richieri and colleagues reported that maintenance TMS was associated with a significantly lower relapse rate in patients with pharmacoresistant depression in routine practice among responders. The clinical information indicates that this patient has pharmacoresistant depression. He achieved remission with TMS, but he has relapsed with symptoms of depression. The patient has experienced a return of depression symptoms and is having difficulty with vomiting which makes oral antidepressant medications difficult and likely ineffective. Since the guidelines have not specified an ideal number of TMS sessions, and patients respond differently to TMS, the number of sessions should focus on the individual patient. This patient has been intolerant to medical therapies yet he demonstrated prior success with TMS. Given these findings, the requested TMS 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 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: Upheld

The patient has requested authorization and coverage for Zembrace SymTouch 3 mg/0.5 mL pen injector. Sumatriptan is a triptan with a long-established history of use in the acute treatment of migraine headaches (Derry, et al). Sumatriptan is available in tablet, nasal spray, inhaled and injectable formulations. In this case, the patient has been prescribed Zembrace SymTouch, which is one of the injectable formulations of sumatriptan. While various formulations of injectable sumatriptan are available, there have been no comparison studies completed amongst the formulations. In this case, the Health Plan has authorized sumatriptan formulations Imitrex cartridge and syringe, and Alsuma pen injector. The records do not document an adequate trial of, or a contraindication to, treatment with these medications. Given these findings, the requested Zembrace SymTouch 3 mg/0.5 mL pen injector is not medically necessary for treatment of this patients migraine headaches. 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 neurology with subspecialty certification in sleep 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has chronic low back pain and myofascial pain, and has requested authorization and coverage for the medication Belbuca. The Health Plan indicated that it had not been determined that all covered formulary drugs on any tier would be ineffective. Or would not be as effective as the requested non-formulary drug, or would have more adverse effects than the requested non-formulary drug. There are other alternative drugs available which the patient has not tried and failed.At issue in this case is if the medication Belbuca is medically necessary to treat the patients medical condition.The Center for Disease Control (CDC) guideline does not support chronic opiate maintenance for non-malignant low back pain. The assertion that transdermal Buprenorphine is safer is not evidence-based. Studies have demonstrated that opiates were not superior to treatment with non-opioid medications for improving pain related function over a 12-month period. The patient does not have a documented source of low back pain, and the evidence does not support chronic opiate use in this clinical setting. Therefore, the requested Belbuca is not medically necessary. 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 anesthesiology with subspecialty certification in pain 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: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees hyperhidrosis of the forehead.  Findings:  The physician reviewer found that based upon review of the medical records, treatment of this patients hyperhidrosis of the forehead with Botox has been shown to exceed in efficacy other treatment methods. In addition, there is medical literature supporting its clinical safety and efficacy for this condition (Santana-Rodriguez, et al). One study from Kinkelin and colleagues demonstrated Botox to be effective for 5-9 months in patients with frontal hyperhidrosis. Moreover, Benohanian concluded that, Botulinum toxin type A has revolutionized the treatment of focal hyperhidrosis in recent years and has dramatically reduced the invasive surgical techniques that have been performed in the past to control severe focal hyperhidrosis unresponsive to topical therapies. Given this patients failure to respond to conservative therapies and positive outcome with Botox injections, the requested therapy should be considered the most appropriate in this clinical setting. These salient points justify medical necessity for Botox injections in the patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested CyberKnife radiosurgery for the treatment of his prostate cancer. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has localized prostate cancer, which is highly curable using different radiation techniques. Although CyberKnife treatment is a relatively new treatment, this technique is more conformal in terms of dose delivery than any other available method of delivery. The use of CyberKnife is medically appropriate and indicated in this case and should be authorized
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested a surgical consult for bariatric surgery and follow-up for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The medical records note a body mass index of 48.42.  This patient has several comorbid conditions, including degenerative joint disease and sleep apnea.  She has failed dietary efforts and is an appropriate candidate to undergo a bariatric surgery consult.  The current medical evidence supports the requested services in this setting.  All told, the requested consult for bariatric surgery and follow-up are medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections, series of two. The submitted documentation supports the medical necessity of the requested services. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the authors, the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function. The authors noted that viscosupplementation has a good safety profile. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc One injections, series of two is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

The parent of a seven-week-old male enrollee has requested Synagis therapy for Respiratory Syncytial Virus (RSV) prevention. Findings:  The physician reviewer found that although this patient does not meet all of the criteria as set forth in the AAP guidelines, he is at risk for significant morbidity and even mortality from RSV disease by virtue of his gestational age, gender, and birth weight, as demonstrated by numerous studies.