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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Femring 0.1 mg. Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. Vaginal atrophy causes bothersome vaginal symptoms commonly associated with menopause including vaginal or vulvar dryness, discharge, itching and dyspareunia. Local vaginal estradiol and local conjugated equine estrogen, which can be administered in cream, ring and tablet formulations, are effective in treating this condition. The results of randomized controlled trials show that even low-dose vaginal estradiol tablets can improve vaginal symptoms. Although studies indicate that the three-month estradiol-releasing vaginal ring is preferred to cream because of greater comfort, ease of use and satisfaction, there is also some data to suggest there may be a greater systemic absorption with this formulation. Because of variable rates of estrogen absorption associated with local estrogen therapy, there has been concern about the use of this treatment in women with a history of breast cancer. Since local estrogen treatment in the forms of creams, inserts and rings have all been found to be similarly effective in relieving the symptoms of vaginal atrophy, the patient can be treated with the Health Plans formulary alternatives including Yuvafem. In addition, given the patients history of breast cancer, it is prudent to choose the lowest dose preparation of local estrogen. For these reasons, the requested Femring 0.1 mg is not supported as medically necessary for treatment of this 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment center (RTC) services were medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient meets the criteria for residential level of care. Medical necessity dictates that the patient be treated in the least restrictive setting possible. This patient had already failed outpatient treatment and had failed PHP, after an entire month of treatment. She then had three acute psychiatric hospitalizations with readmissions only days after her discharge, each time for suicidal thoughts and self-harming behaviors. If a patient is acutely suicidal, they are not appropriate for RTC, but should be treated at the acute level. However, once they are stabilized sufficiently, as in this case, it is appropriate for them to be stepped down to RTC where they can remain for a longer period of time, sufficient to make changes in their chronic maladaptive patterns of behavior. Therefore, based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autism. Findings:  Two physician reviewers found that the request for speech therapy is medically necessary. Since plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, it can be utilized to improve overall neurologic health. Specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. As such, the requested speech therapy is medically necessary for treatment of the patients medical condition. Regarding the requested occupational therapy, just as with speech therapy, occupational therapy can also be used to help induce brain plasticity in an attempt to retrain neural circuitry. Occupational therapy is medically indicated along with speech therapy to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities. This multimodal approach will allow the patient to derive therapeutic benefit. Therefore, I have determined that the requested occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 50 minutes of occupational therapy once per week for 20 weeks and 50 minutes of speech therapy once per week for 20 weeks. In a review of the evaluation and treatment of children with autism spectrum disorder, Baumer and Spence noted that optimal treatment involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Researchers concluded that, evidence of the effectiveness of social skills programs is strong for children requiring services at the intensive level (e.g., those with autism spectrum disorder, diagnosed mental illness, serious behavior disorders) to improve social behavior and self-management. This patient has a central auditory processing disorder, sensory processing disorder, delayed expressive and receptive language, and disorder of pragmatic language. The provision of occupational therapy and speech therapy is the standard of care in this clinical setting. Therefore, the requested 50 minutes of occupational therapy once per week for 20 weeks and 50 minutes of speech therapy once per week for 20 weeks are 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: Overturned

The parent of a three-year-old male enrollee has requested speech therapy services for the treatment of the enrollees speech disorder secondary to apraxia and dysarthria. Findings:  The physician reviewer found that this patient is a young child with speech disorder, apraxia, and dysarthria, whose skills fall below those of other children his age. These deficits negatively impact his ability to communicate effectively. However, he has demonstrated improvement with speech and language services. Studies have shown that speech therapy can result in significant improvement in such patients.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for a prostate-specific membrane antigen (PSMA) positron-emission tomography (PET) scan (CPT code 78813). The enrollee underwent a prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan to evaluate his response to therapy. His prostate specific antigen (PSA) was 0.3. The record indicates the enrollee has been receiving Lupron and abiraterone to control this disease, as well as radiation. To assess his response to treatment, a follow up scan was performed to compare to his last scan. His physician indicates the effectiveness of his current therapy needed an evaluation in order to decide if more aggressive treatment is needed. Current evidence-based guidelines for the management of prostate cancer were established using computed tomography (CT), magnetic resonance imaging (MRI) and bone scan. Prostate-specific membrane antigen (PSMA) positron-emission tomography (PET)/CT has higher sensitivity and specificity and can lead to changes in disease management. The literature for PSMA PET/CT is mostly in the setting of biochemical recurrence and primary staging of intermediate-to-high-risk prostate cancer. Lack of a globally accepted, standardized reporting system for PSMA PET/CT is a current limitation of this procedure. Such standardization is essential to incorporating this imaging process in clinical trials to assess its impact on outcomes; particularly when upstaging or downstaging conventionally-imaged disease. This would then lead to recognition by healthcare providers, incorporation into guidelines and routine use in clinical practice.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in medical 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision surgery to laparoscopically remove a previously implanted LINX device and to implant a new LINX device.Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. The submitted medical records reflect that the patients current LINX device is functioning well and is well-seated. A post-operative EGD showed no evidence of hiatal hernia, and noted that the LINX device was in good position without erosion or migration. Furthermore, pH testing performed while the patient was off Dexilant, yielded a normal DeMeester score (9.7, normal <14.72), and only physiologic reflux without symptom correlation. Manometry has also demonstrated normal LES pressures. Despite present symptomatology, there is no medical or surgical justification to replace the patients functioning LINX device with another LINX device. Under the circumstances set forth in the submitted documentation, the patients reported distress does not appear to be acid reflux-related. A replaced LINX device would not be anticipated to correct the patients coincidental esophageal dysmotility. Accordingly, revision surgery to laparoscopically remove a previously implanted LINX device and to implant a new LINX device is 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 requested services are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are actively practicing and are board certified in internal medicine, with subspecialty certification in gastroenterology. 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: Overturned

The patient is a 39-year-old male with HIV, lipodystrophy and an inadequate response to arginine/GHRH. The patient has multiple somatic symptoms, which may or may not be related to growth hormone deficiency. The patient has requested authorization and coverage for growth hormone therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary for treatment of the patients condition.The patient meets medical necessity criteria for growth hormone therapy. The submitted evidence indicates he has a low IGF-1 (101). In addition, the patient is HIV positive and has lipodystrophy. Furthermore, the patient has had an inadequate maximum response to arginine/GHRH stimulation testing (a basal level of 5.4 and a stimulated level of 3.9). For these reasons, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS) treatment. The records provided for review document that this patient presents with a history of overactive bladder. The patients provider reported that the available treatment options include PTNS, Botox injections, and sacral nerve stimulator implant. The patient has undergone treatment with Vesicare, Mirabegron, and Toviaz. Per the American Urological Association (AUA), after medication therapeutic failure or intolerance, PTNS is considered the least invasive therapeutic treatment option for patients with overactive bladder (Lightner, et al.). In addition, the AUA considers Botox and sacral nerve stimulators as more invasive treatments that should be reserved for patients who have failed behavior modification and pharmacologic therapy. This patients condition has failed to improve despite treatment with multiple medications and behavior modification. For these reasons, the requested PTNS treatment 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that based on the records provided, this patient has increased coronary risk, including hyperlipidemia, but no symptoms or objective findings of obstructive coronary disease and no documentation to support a diagnosis of familial homozygous or heterozygous hyperlipidemia. These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit any of those criteria. PCSK9 inhibitors have not been studied in other patient populations, such as this patient. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. 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 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: Upheld

The patient is a 15-year-old male with a history of bipolar disorder and polysubstance abuse. He was admitted to residential treatment after a three-day hospitalization following a suicide attempt. Treatment in residential care included Trazodone, Lithobid, and Risperdal. The patients last measured lithium level returned at a value of 1.0.A request has been made for continued psychiatric residential treatment services. The Health Plan indicates the submitted information demonstrates that as of 6/7/04 continued psychiatric residential treatment services were not medically necessary.The Health Plans denial should be upheld. The submitted information provides no evidence that the patient is acutely ill from affective or aggressive standpoints. Additionally, based upon the information provided the patient was not actively suicidal by the point of 6/7/04. As of 6/7/04, the patients condition stabilized to the point that residential treatment services were no longer medically indicated and transition to a partial hospitalization program would have been medically reasonable and appropriate. Therefore, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
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: Two physician reviewers found that the medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to mammography has gained popularity due to an associated decrease in callbacks and increased rate of detection of small cancers.  This improvement using tomosynthesis is due to the tomographic feature of the technique and associated ability to separate out superimposed dense breast tissue from potential pathology.  All told, the addition of breast tomosynthesis was likely to have been of greater benefit in this patients case than two-dimensional mammography alone.Final Result: Two 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator.Findings: Two of the three physician reviewers found that this patient has obstructive sleep apnea. The records documented nasal obstruction with inferior turbinate hypertrophy and septal deviation. There has been no treatment of the nasal obstruction which contributes to sleep apnea. The patient has not been able to tolerate the CPAP device. The Inspire device is an FDA approved device for the treatment of OSA device. At this point, the patient is not a candidate for the Inspire device given the nasal obstruction has not been addressed medically or surgically. Therefore, the requested implantation of a hypoglossal nerve stimulator is not likely to be of greater benefit than other treatment options.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Xifaxan for treatment of the enrollees small intestinal bacterial overgrowth (SIBO). Findings:  The physician reviewer found that the patient has small intestinal bacterial overgrowth and the records note treatment and failure of two formulary alternatives. Xifaxan has been highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo. The medical literature also indicates that the medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones.  Results are sustained for several weeks after treatment. One more recent study has corroborated this finding. A prospective trial of patients with irritable bowel syndrome and a positive breath test found that 86% responded to Xifaxan, and symptoms were reduced as well. For these reasons, the use of Xifaxan tablets is medically necessary for the treatment of this patients small intestinal bacterial overgrowth. 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.
Appeal type: Urgent Care
Decision: Upheld

A 55-year-old female enrollee has requested for emergency transport services indicating that her condition was emergent in nature. Findings:  The physician reviewer found that the patient complained of persistent cough/congestion that had been getting worse. Per the ambulance records, she had no complaints of chest pain, shortness of breath, nausea/vomiting or trauma. The evidence demonstrates that the patient did not have a condition that would lead a prudent layperson to believe that he or she required immediate medical attention or ambulance transport since the patient was not short of breath, experiencing chest pain or toxic in appearance. It typically takes at least 48 hours to see improvement in bronchitis symptoms when on antibiotics. The fact that the patient had not improved within a 24-hour period would not be considered a reason to seek immediate medical attention by a prudent layperson. Furthermore, the fact that the patient left the emergency room without being seen suggests that her symptoms were not severe