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

Physician 1: This case involves a 60-year-old female who indicates she has refractory migraine headaches. She has received Botox injections in the past, which she reports have been effective in relieving her headaches. The patient has requested reimbursement for the Botox injections at issue. The Health Plan has denied coverage for Botox on the basis it is considered investigational for treatment of migraine headaches. There are a variety of safe and approved medications, either for prophylactic use or for occasional acute bouts of headaches. The submitted records fail to provide sufficient information and details concerning the patients headaches or medications that have been tried in the past. Thus, there is inadequate evidence the patients headaches were refractory to standard therapies. As such, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 60-year-old woman with a reported history of refractory migraine headaches. The submitted records do not specify the patients past history of medications used to help alleviate her symptoms. The patient received Botox injections in May and June 2004. Her physician indicates she has had a positive response to Botox. The patient is requesting reimbursement for the injections. The Health Plan has denied this request indicating there is insufficient evidence Botox therapy is efficacious for migraine headaches.Though there is growing evidence supporting the use of Botox for treatment of migraines refractory to multiple prophylactic medications, the submitted records do not provide sufficient detail regarding the patients previous use of prophylactic therapies. As such, the severity and refractory nature of the patients migraines has not been established. Therefore, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 60-year-old female who indicates she has refractory migraine headaches. She indicates that she has received Botox injections, which provided effective headache relief. The Health Plan has denied reimbursement for the Botox injections at issue on the basis Botox is considered investigational for treatment of the patients condition. The submitted materials do not include detailed information regarding the patients history, prior therapies, or current therapy. Nor is there sufficient documentation of the patients response to Botox in the clinical notes provided. As such, it has not been established that Botox was likely to be more beneficial for treatment of the patients medical condition than any available standard therapies. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that 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 it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging alone. Accordingly, the digital 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for the evaluation of her medical condition.  Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided above, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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:  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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cologuard test. Findings:  The physician reviewers found that evidence on impact or on healthcare outcomes of Cologuard versus standard medical care is lacking at this time. Cologuard is not standard of care. Cologuard is U.S. Food and Drug Administration approved to test for colon cancer.  However, the limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard, raising concern that Cologuard may miss cancer. The evidence of the impact of Cologuard on patient care or health outcomes is also lacking. There is a lack of consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes, as national guidelines from The United States Preventive Services Task Force and the American Cancer Society currently disagree (ACS guidelines; USPSTF recommendations). Notably, the USPSTF states that the specificity of FIT-DNA (Cologuard) is lower than that of FIT alone, which means it has a higher number of false-positive results and higher likelihood of follow-up colonoscopy and experiencing an associated adverse event per screening test. There are no empirical data on the appropriate longitudinal follow-up for an abnormal FIT-DNA test result followed by a negative colonoscopy; there is potential for overly intensive surveillance due to clinician and patient concerns about the implications of the genetic component of the test. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer.  For these reasons, Cologuard is not likely to be more efficacious for evaluation of this patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for evaluation 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 gastroenterology 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

The patient is a 51-year-old female with metastatic GI stromal tumor (GIST). She underwent chemotherapy and surgery in 2005. The patient had CT scans in January 2006 and April 2006 and PET/CT scans in August 2005 and April 2006. A follow-up CT scan performed in July 2006 showed no change in the right pleural effusion, and slight decrease in the right lower lung atelectasis/infiltrate. Within the liver there had been a decrease in a right lobe lesion, new left lobe and caudate lobe lesions, and enlargement of lesions in the right and left lobes.The patients clinician has requested a follow-up PET scan to further evaluate the patients disease. The Health Plan has denied coverage for the proposed PET scan on the basis that it is not medically necessary.Prior CMS reimbursement standards included a limited number of cancers on its list of indications for PET scan. However, the National Oncologic PET Registry was developed in response to the Centers for Medicare and Medicaid Services (CMS) proposal to expand coverage for PET scans to include cancers and indications not previously eligible for Medicare reimbursement. Connective tissue and other soft tissue tumors are now listed, with PET scan being indicated for diagnosing, initial staging, treatment, monitoring and restaging/suspected recurrence of disease.It has been shown that PET (PET/CT) is helpful in the staging and restaging of GIST and has an impact on clinical decision making in these patients. In addition, the patient has had prior PET exams to evaluate her disease thus adding to the significance of changes on a follow-up exam. Accordingly, I have determined the requested PET scan is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing facility treatment services (medications, nursing, physical therapy and occupational therapy) for treatment of her medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for skilled nursing facility care has not been established. In this case, the patient has Guillian-Barre Syndrome (GBS) which is a polyneuropathy that can manifest with extreme weakness. Recovery occurs over months to years. GBS is accompanied by deficits of functional mobility and self-care that are at times profound. The functional deficits have traditionally been treated with comprehensive rehabilitation. A systematic review of multidisciplinary rehabilitation found low quality evidence that inpatient multidisciplinary rehabilitation may improve disability and quality of life in the short term. In this case, the patient has shown improvement to the point where intensive physical therapy in the inpatient setting was no longer needed. She did not demonstrate a need for skilled nursing or speech therapy services. She had continued deficits of self-care that can be addressed with custodial care and outpatient therapy. Continued skilled nursing facility treatment services were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned

A 27-year-old female has requested a functional electrical stimulator (RT300 FES Cycle Ergometer Rehabilitation Therapy System) for treatment of her tetraplegia.   Findings:  Two physician reviewers found that the patient reports that as a result of having discontinued use of the device she has experienced disuse muscle atrophy, increased spasms, and recurrent urinary tract infections. A letter of medical necessity completed by the provider indicates that the patient has had an excellent clinical response to the device during trials and that the device is medically necessary for ongoing in-home treatment of the patients condition. The health risks of inactivity/immobility following spinal cord injury have become increasingly well recognized and the benefits of a regular exercise program have been established repeatedly in the literature. Substantial barriers limit access to regular exercise in the SCI population and use of in-home FES ergometry has become increasingly common.  Numerous studies have demonstrated the clinical benefits of FES cycle ergometry in persons with spinal cord injury. Some of these health benefits have included improved circulation, cardiac function, and overall fitness. Given the ease of access of in-home FES ergometry and its health benefits in the spinal cord injury population, it is likely that the RT 300 FES cycle ergometer would be more beneficial than alternative standard therapies for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested authorization and coverage for Requip XL 12mg for treatment of the enrollees Parkinsons disease.  Findings:  The physician reviewer found that based on review of the available records, this patient has a diagnosis of Parkinsons with described symptoms consistent with that diagnosis. He has been treated with a dopamine agonist, Requip, with reported benefit. Requip has a short half life of five to six hours, and thus immediate release preparations need be taken three to four times per day. The Requip XL preparation and immediate release preparation are not the equivalent. A medical literature review reveals that treatment adherence, and thus treatment results, are enhanced by less frequent dosing, and are worsened with more frequent dosing across a variety of chronic conditions. This patients statement that it is more difficult to adhere to a less frequent dosing schedule is clinically reasonable and supported by the literature. Therefore, use of Requip XL, which requires less frequent dosing, is supported as medically necessary in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for comprehensive day treatment, consisting of clinical therapies (occupational therapy, speech therapy, physical therapy, and psychotherapy), six hours per day, five times per week for treatment of the enrollee who has a history of traumatic brain injury. Findings:  The physician reviewer found that there is a lack of support in the medical literature of the requested services in this clinical setting. The patient is more than one year status post traumatic brain injury as noted in the records. The medical evidence indicates that most recovery occurs in the first six to 12 months. However, recovery can extend beyond one year and neurologic recovery continues for perhaps up to two years. In this patients case, based on the reported progress with the patients current treatment program, the patient appears to have reached a functional plateau consistent with the severity of his residual neurological deficits. The documentation provided does not support a reasonable expectation that this patient will show a measurable, practical improvement in his functional status within a reasonable period of time. As such, there is not a reasonable expectation that an intensive rehabilitation therapy program would significantly affect this patients condition when compared with therapy provided at a less intense level of care. The medical literature supports continued through a home exercise program with assistance from non skilled caregivers with intermittent skilled therapy oversight. A periodic reassessment of his neurological condition can be performed to determine the potential for measurable gains within a reasonable and predictable period of time and need for further skilled therapy at a higher level. Based on the records provide, this patient does not meet the criteria for the intensity of services being requested. Therefore, comprehensive day treatment, consisting of clinical therapies (occupational therapy, speech therapy, physical therapy, and psychotherapy), six hours per day, five times per week are not medically necessary for the treatment of this patients medical condition. 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for repair of her power scooter for treatment of her multiple medical conditions. Findings:  The physician reviewer found that the records provided for review do not establish that the patient would be bed or chair confined without a power mobility device. The records also do not substantiate any significant neurological or musculoskeletal impairment or pathology affecting the patients upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to the degree that would preclude her from accomplishing her mobility related activities of daily living (MRADLs) in the home using a walker or manual wheelchair. Overall, the repair of the patient's power mobility device is not medically necessary for this patient, given that she is independent with respect to her MRADLs in the home and given that her mobility deficits can be addressed by other means.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 11-year-old male who is of short stature. The patient was referred to a pediatric endocrinologist who recommended the patient receive growth hormone therapy. The Health Plan has denied authorization for growth hormone therapy indicating it is not medically necessary for treatment of the patients condition.  The submitted information does not demonstrate growth hormone therapy is medically necessary for this patient. There are no records from the patients primary care physician explaining the reason for the referral to pediatric endocrinology. Furthermore, it appears the submitted evidence includes contradictory growth velocity information. The information provided does not establish that growth hormone therapy is medically appropriate or indicated for this patient. 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: Medical Necessity
Decision: Upheld

A thirty-two year-old female with a history of neck pain is requesting reimbursement for an anterior discectomy and fusion.  Reviewers Findings:  The reviewing physician found that there is no objective evidence in the record to indicate that inpatient admission and operative intervention were warranted for the treatment of the patients neck symptoms.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Norco for treatment of his chronic pain. Findings:  The physician reviewer found that the request for Norco is not medically necessary. This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The patient should wean off short-acting opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. Moreover, long-term, short acting opiates may cause adverse outcomes. Based on the documentation submitted for review and the peer-reviewed literature, the requested Norco is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy treatment of his autism and expressive and receptive language delay. Findings:  The physician reviewer found that recent data suggests that older children diagnosed with ASD can benefit from access to speech therapy. In a recent article, it was shown that direct one-on-one intervention with a speech and language therapist can be effective for all areas of language for older children with developmental language disorder, regardless of their gender, receptive language or ASD status, or age. While these results are encouraging, in this case, the patient has received direct one-on-one speech therapy for many years, and has failed to demonstrate progress necessary to support the medical necessity for continued therapy. Final Result: The reviewer determined that the requested service 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.