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

A 32-year-old female enrollee has requested for a magnetic resonance imaging of the pelvis/uterus for evaluation of her uterine anomaly.  Findings:  The physician reviewer found that Olpin and Heilbrun, MRI is the best imaging method available because of its superior ability to reliably visualize complex uterovaginal anatomy. MRI has emerged as the universally accepted standard in the imaging evaluation of Mullerian duct anomalies. Overall, MRI provides excellent delineation of both internal and external uterine anatomy with accuracies of up to 100% in the evaluation of Mullerian duct anomalies. One of the most valuable features of MRI in the evaluation of pelvic anatomy is the multiplanar imaging capability which allows the contour of the uterine fundus to be visualized. This data is essential for the evaluation of Mullerian duct anomalies. T2-weighted images provide excellent detail regarding uterine zonal anatomy and are considered the mainstay of pelvic imaging. The endometrium is uniformly hyperintense on T2-weighted images. The junctional zone surrounds the endometrium, and is readily identified as a hypointense band measuring between 8 to 10 mm in thickness. The uterine myometrium surrounds the junctional zone and is of intermediate signal intensity on T2-weighted images. T1-weighted sequences are used to identify blood products, which can be very helpful when obstructed Mullerian duct anomalies result in hematometrocolpos.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech impairments. Findings:  The physician reviewer found that this young man has significant speech and language deficits involving expressive language skills, negatively impacting his ability to communicate and maintain social interaction. It is not typical for speech and language disorders to arise de novo in the adolescent years unless associated with neurologic disease or trauma. This young man does not have either in his medical background. His therapist has diagnosed him with an adjustment disorder with anxiety. While anxiety may result in rapid speech, the examples of the patients speech patterns included in the documentation reveal more deficiencies than just rapid speech. In fact, it may be that he has had speech and language deficits all along, partially masked by his bilingual background, yet concurrently exacerbated by and exacerbating his anxiety. Prathanee and colleagues (2006) looked longitudinally at children with a history of specific language impairment. Natural history data indicated that approximately 50% of children with specific expressive language delay spontaneously remitted or outgrew it at age 5-8. However, long-term follow-up studies showed their language problems emerged later at age 15. The rest of the childrens (50%) language impairment persisted and had a high risk for SLI [specific language impairment] later. They recommended active intervention for these children. Speech and language therapy is thus medically necessary and appropriate for this young man. In addition, neuropsychological testing would be quite helpful in delineating mental health issues from processing difficulties and language deficits.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 1-year, 10-month-old male enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees expressive 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 and 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 varies with disorder type, severity, age, and the etiology of the condition. For this reason, a complete work-up to assess possible etiologies of the patients condition is essential. As speech therapy is the standard of care for patients with speech delay, the requested therapy is medically necessary for this patient at the frequency of two, one-hour sessions per week.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested the medications pegylated interferon and ribavirin for the treatment of his hepatitis C. Findings:  Two physician reviewers found that optimal management of a patient with hepatitis C who fails therapy is unknown.  Two studies address the use of alpha-2b interferon in the treatment of patients who failed therapy with standard interferon and ribavirin. In these studies, overall response for re-treatment was 16% (Jackson, et. al.) and 23% (Taliani, et. al.). In the recent Mayo Clinic Study (Cheruvattath, et. al.), 10% of the patients retreated with pegylated interferon and ribavirin had a sustained virological response. All told, there is sufficient evidence to support the treatment of this patient with pegylated interferon alpha and ribavirin.
Appeal type: Experimental/Investigational
Decision: Upheld

A 20-year-old female enrollee has requested IVIG treatments for treatment of her medical condition. Findings: Two physician reviewers found that the long-term safety and efficacy of using IVIG for complex regional pain syndrome (CRPS) or fibromyalgia has not been established. Although one study showed the potential promise of this therapy for CRPS, these results need to be repeated in a longer study with more patients before it can be recommended for this population.  IVIG is not a benign therapy. It should not be used until its safety and efficacy has been clearly established for a disease. The side effects from IVIG may include stroke, heart attack and renal failure. IVIG is not an approved therapy for CRPS. Until additional studies can be performed, it should be avoided as a treatment alternative for CRPS patients. Of further note, in this patients case there are no laboratory findings or clinical findings that meet the American Academy of Neurologys diagnostic criteria for chronic inflammatory demyelinating polyneuropathy. In fact, the patient is documented to have non-pathological reflexes, and this is a finding not consistent with chronic inflammatory demyelinating polyneuropathy. To this end, this diagnosis cannot be used as an indication for IVIG in this patient. All told, in this patients case, IVIG treatments were not and are not likely to be more beneficial than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) level of care at the AToN Center. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment.  In this particular case, the patients alcoholism was central to his daily routine and contributed to his significant impairment across multiple domains of functionality.  He had health issues related to his drinking. He had a strained relationship with his significant other.  He had co-occurring depression and rigid personality traits.  He was prescribed antidepressant and anti-craving medication. The documentation provided did not indicate that this patient had consolidated the treatment gains necessary to succeed in the outpatient setting.  Instead, the patient was anxious prior to a family session and described as depressed a few days later.  It was not until the final week that the patient fully accepted his alcoholism. Thereafter, he continued to bolster his motivation for recovery and relapse prevention, and develop aftercare planning, while his anti-craving medication was changed from oral to a long-acting injection.  The services and setting were safe, appropriate and consistent with good practice while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness.  In sum, considering the clinical presentation and relevant peer-reviewed literature, RTC level of care at the AToN Center was medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were 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

This patient is a three-year-old male with a history of chronic ear infection requiring ear tube placement. The patient also has a history of moderate to severe delayed speech and language production. He had been receiving speech therapy once weekly with some goals being met. Of note, the patient missed multiple visits due to ear infections. Since that time he has been receiving speech therapy three times per week. The patients provider has noted multiple improvements in word production, but functional use of these words to communicate the patients wants and needs was inconsistent at the time of the follow-up evaluation. The patients therapist is recommending one-hour speech therapy sessions three times per week. At issue is whether it is medically necessary for the patient to receive three speech therapy sessions per week to improve his verbal apraxia.Review of the medical literature does not reveal any studies evaluating the frequency of speech therapy for patients such as this patient. The Health Plan has authorized speech therapy at a frequency of twice per week. There is no evidence that speech therapy three times per week results in a better clinical outcome than speech therapy two times per week. Therefore, the services authorized by the Health Plan are medically reasonable and appropriate and sufficient to treat the patients apraxia. As such, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees Mobius syndrome with right hemiparetic cerebral palsy.   Findings:  The physician reviewer found that Mobius syndrome is a rare disorder characterized by mask-like faces with 6th and 7th cranial nerve palsies. Neurodevelopmentally, these features may be due to hypoplasia of the corresponding brain stem nuclei, destructive degeneration of central brain nuclei, myopathy, or peripheral nerve involvement. Up to 30% of affected patients are cognitively delayed. Hearing loss, most frequently due to chronic otitis media, is common as is impaired speech in the majority of cases. Over time, the lack of facial expression can result in problems with social interaction and acceptance. According to the publication by Sjogreen and colleagues, Early intervention by a speech pathologist and a paediatric dentist should be undertaken to improve orofacial function and symptoms. This young patient with Mobius syndrome has anatomic and functional abnormalities resulting in difficulties with speech and language development. Thus, comprehensive speech evaluation and therapy are medically necessary and the standard of care within the community.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Findings: The physician reviewer found that while this patients record may not support advanced fibrosis, current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Also per the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with the patients characteristics. `Once-daily ledipasvir-sofosbuvir with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. (Afdhal, et al; Gentile and Borgia). In sum, Harvoni is medically necessary for treatment of the patients hepatitis C infection.  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.Qualifications/Credentials:  The physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne gene test. In keeping with the standard of care as summarized in National Comprehensive Cancer Network (NCCN) for colon cancer, only KRAS, NRAS, BRAF, and MSI genomic molecular markers have been demonstrated to provide improved health outcomes. To demonstrate clinical utility of panel testing for somatic genomic alterations such as FoundationOne assay, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of any benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is not supported for use in this clinical setting. Thus, the KRAS, NRAS, BRAF, and MSI portions of the testing were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical 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: Upheld

The parent of a 12-year-old male enrollee has requested continued growth hormone (GH) therapy for treatment of his neurosecretory dysfunction.   Findings:  The physician reviewer found that before growth hormone therapy was initiated, the patients IGF-1 level was borderline low at 100ng/ml, his IGFBP-3 was normal at 5.0 ng/ml and his thyroid function test results were normal. Provocative GH stimulation testing after arginine and clonidine gave appropriate GH responses with a peak result of 15.8ng/ml. The patients bone age was delayed by approximately three years. His estimated adult height at that time would have been 58 exceeding the mid-parental height in the male tables of the Greulick and Pyle Atlas. The current mid-parental height estimate is 56.5. This patient appears to have a constitutionally delayed adolescence and would be expected to attain a normal adult height without GH therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG) infusions at 2 g/kg monthly for a duration of six months.Findings:  The physician reviewer found that Pediatric autoimmune neuropsychiatric disorders associated with streptococcal (PANDAS) has been described as the acute onset of obsessive-compulsive disorder (OCD) and/or motor tics in children following recent streptococcal infection. Symptoms frequently relapse and remit, and may respond poorly to psychotropic medications (Murphy, et al.). This patients rheumatologist, psychologist, psychiatrist, and pediatrician concur with the recommendation to continue monthly infusions of IVIG and Solu-Medrol. The records document that the patient has experienced an extremely severe form of OCD with tics, associated with severe, self-injuries, which have resulted in permanent scarring. She has been treated with multiple psychoactive medications with minimal improvement, required several prolonged inpatient hospitalizations, and she has required sedation in an intensive care unit on several occasions to prevent her from seriously injuring herself. Although there has been debate in the literature regarding its efficacy, in this particular patients case, there is a well-documented dramatic improvement in her symptoms after administration of IVIG, with subsequent devastating return of symptoms and regression when IVIG treatment has been delayed. The patient has undergone an appropriate diagnostic evaluation, including a spinal tap and MRI studies. In this specific clinical setting, the medical records support the efficacy of IVIG for this patients symptoms. Therefore, the requested Gammagard IVIG infusions at 2 g/kg monthly for a duration of six months are medically necessary for 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG). The American Academy of Neurology (AAN) guidelines for IVIG in the treatment of neuromuscular disorders recommends that IVIG should be considered in the treatment of myasthenia gravis. The AAN noted that further studies on the safety and efficacy of IVIG in myasthenia gravis are lacking due to the few randomized trials and small study sizes available at this time. Researchers reported that there is class 1 evidence for the use of short-term IVIG in patients with worsening myasthenia gravis and good evidence for IVIG use in myasthenic crisis. However, for long-term maintenance therapy, there is a paucity of controlled studies and the evidence is limited to class III retrospective studies. In this case, the records provided for review do not document the severity of the patients disease to warrant the use of IVIG. The records suggest that the patient has been treated with IVIG as a long-term therapy, but the clinical evidence does not report on the benefits of IVIG or the patients specific response to treatment. The records also do not provide enough evidence of an inadequate response to immunosuppressive therapy. For these reasons, the requested IVIG is not medically necessary for 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 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.