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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira every week.Findings:  The physician reviewer found that clinical literature supports the use of Humira 40 mg weekly for the treatment of ulcerative colitis in this patients case. The submitted documentation notes that this patient did not have adequate response to Humira 40 mg every other week. In the ULTRA 1 trial, which was a high-quality, randomized, double-blind, placebo-controlled trial, weekly use of Humira allowed an increase in maintenance of remission. In the ULTRA 2 trial, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks. The trial advanced responders and non-responders at week eight to weekly therapy. Both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly Humira was started for inadequate response or for flare. In a subset analysis of ULTRA 2 patients, those on weekly therapy had week-52 response rate of 25% after failing therapy given every two weeks. These data apply to this patients case. The medical literature on the use of Humira for ulcerative colitis supports use of 40 mg weekly. For these reasons, the requested treatment with Humira weekly is supported as medically necessary for the treatment of this patient medical condition.Final Result: The reviewer determined that 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 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 two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.   The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, behavior, socialization, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  The current medical literature supports the requested therapy in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that breast 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.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breast tissue.  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. Thus, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in 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 reimbursement for the genetic testing for evaluation of the enrollees major depressive disorder. Findings: Three physician reviewers found that the documentation provided does not indicate that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence based psychotherapy trials. In addition, there is no documentation that the patient has been treated with psychotherapy. The literature supports outpatient treatment as well as family therapy in managing suicidal ideation and behaviors for adolescents. Moreover, the current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy. The current evidence indicates that the patient could benefit from psychotherapy for her behavioral health condition. The evidence base does not support the use of pharmacogenomic testing in this clinical setting. One study noted that there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice. Another study reported that routine application of pharmacogenetic dose adjustment in clinical practice requires prospective validation. Final Result: Three physician reviewers determined that the testing at issue was 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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

Physician 1: The patient is a 39-year-old male with an ankle injury. His provider recommended a right ankle osteochondral allograft procedure, which was performed in January 2005. The Health Plan has denied reimbursement for the procedure indicating it is considered investigational for treatment of the patients medical condition.Osteochondral allografting is an accepted procedure, which is performed specifically in cases such as this. The procedure provides coverage of cartilage where it is missing in order to alleviate pain and avoid fusion. Osteochondral allografting is clearly superior to ankle fusion for patients such as this patient. Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is an active 39-year-old male who had a climbing accident and sustained multiple injuries including a fracture dislocation of the right ankle. He underwent surgical repair with internal fixation and subsequent removal of hardware. In January 2005 he underwent an osteochondral allograft for severe ankle arthritis. Since the procedure the patient reports ongoing continued improvement in ankle function as well as relief of pain. Reimbursement for the procedure has been denied by the Health Plan on the basis that the procedure is considered investigational.Osteochondral allograft has had documented success and was likely to result in a superior clinical outcome over standard therapies in this case. With the osteochondral allograft, the patient has the capacity to retain some mobility, which is lost with a fusion. Furthermore, if subsequent problems develop the procedure is amenable to revision of the grafting or, if necessary, fusion would still be a viable option. As such, I have determined the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 39-year-old male with post-traumatic ankle arthritis. An osteochondral allograft procedure was performed in January 2005. He is requesting reimbursement for the procedure, which has been denied by the Health Plan.Osteochondral allograft transplantation for post-traumatic ankle arthritis is an unproven treatment. The long-term results remain unknown. The standard of care for the diagnosis is ankle fusion. The results of ankle fusion surgery are excellent for this condition. Therefore, I have determined that the procedure 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested  the LifeVest Wearable Cardioverter Defibrillator for treatment of her medical condition.  Two physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the requested device in this patients case.  The requested device in the setting of a newly diagnosed dilated cardiomyopathy has not been documented to positively impact mortality during the period of initial treatment.  If a patient fails to improve ejection fraction to greater than 35% after three months of maximally tolerated treatment, she would meet the criteria for placement of an implantable cardioverter defibrillator.  Per the submitted documentation, the patient was only being treated with a small dose of Coreg, she was not on an angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy, and she was not on a diuretic or aldosterone antagonist.  Therefore, she had not been subject to or failed three months of maximal therapy and did not meet criteria for wearable cardioverter defibrillator or implantable cardioverter defibrillator placement.  In addition, no mortality benefit has been demonstrated in such patients during this three month period when they are treated with a wearable cardioverter defibrillator.  Therefore, the requested LifeVest Wearable Cardioverter Defibrillator is not likely to be of greater benefit than other treatment alternatives.   Final Result: Two reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 49-year-old male enrollee has requested Procrit for treatment of his diagnoses of sickle cell anemia. Findings:  Two physician reviewers found that this patient has had serious complications from sickle cell anemia.  He has been appropriately treated with Hydrea (hydroxyurea), which has been proven in randomized trials to reduce the rate of complications such as pain crises and acute chest syndrome.  Unfortunately, hydroxyurea also induces cytopenias and can exacerbate the anemia that is already present in many sickle cell anemia patients.  There are studies that show benefits from erythropoietin therapy when used in combination with hydroxyurea in increasing the hemoglobin F concentration.  There is adequate medical evidence supporting the requested medication in this setting.  Therefore, Procrit is likely to be more effective than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 61-year-old male who is requesting authorization to have carpal tunnel release performed by a neurosurgeon rather than an orthopedic surgeon as proposed by his Health Plan. At issue is whether a referral to a neurosurgeon is medically necessary.The patient and his neurologist are requesting that the surgery be performed by a neurosurgeon. The Health Plan has proposed that an orthopedic surgeon perform the procedure. Neurosurgeons receive a substantial amount of training in carpal tunnel release as a standard part of their residency. The submitted evidence does not establish that orthopedists have training and experience in this surgical procedure that is equivalent to a neurosurgeon. Therefore, I have determined that the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested for acute inpatient psychiatric hospitalization for treatment of her schizoaffective disorder. Findings:  The physician reviewer found that all told this patient did not and does not meet patient criteria for the acute inpatient psychiatric hospital setting in that she had dramatically approved and does not require 24-hour supervision, did not and does not have suicidal intent and did not and does not show any thoughts that she could not care for herself (as was noted upon her initial admission). Based on this patients prior history of auditory hallucinations to harm herself, not following medication protocol and inability to care for herself the partial hospitalization program (PHP) level of care would be the most appropriate setting in which to treat her behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 31-year-old female who underwent augmentation mammaplasty approximately nine years ago. She was seen and evaluated by her primary care physician in May 2005 for complaints of sudden onset of bilateral breast pain, flu-like symptoms and lymphadenopathy. Further evaluation by a plastic surgeon included appropriate examination and radiological and ultrasound examinations. None of the patients studies have been revealing as to pathology. However, the patient has continued to report bilateral breast pain. The patients plastic surgeon has requested authorization for removal of the patients breast implants.The submitted medical records do not demonstrate removal of the patients breast implants is medically indicated. It appears the patient requires further workup to identify the cause of the mastodon and lymphadenopathy. The proposed procedure involves several significant complications. Furthermore, given the lack of information regarding the cause of the patients symptom, the likelihood the proposed procedure will result in symptomatic relief is unknown. Based upon the information provided, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment for treatment of his schizophrenia. Findings:  The physician reviewer found that based on the available documentation, the patient could have been treated in a lower level of care. The provider noted doubts regarding the patients primary diagnosis of schizophrenia, and it was indicated that the patients primary diagnosis was a substance use disorder. The patient denied any suicidal or homicidal ideation. There was no evidence that the patient was not compliant with medications or staff direction, the patient was medically stable, and there was no documentation that the patient was sleeping poorly or not eating. There had not been any medication changes with the patient for weeks. The patient continued to have poor insight, paranoia, and substance seeking behaviors, and continued to require treatment, but the patient was a candidate for treatment in a less restrictive setting. Final Result: The reviewer 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested continued ABA therapy for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation includes observations and direct interventions on a daily basis made by identified individuals. The medical records document pre-treatment measures of performance. There appears to have been minimal, but clinically significant, gains demonstrated by improved scores on observation material provided. The areas of clinical improvement include eye connect, appropriately seeking help, aural, motor and articulation skills, fine motor skills, question asking skills and several other areas of endeavor.  In no area did the patient regress. This information appears to negate most of the basis for the Health Plans denial. ABA therapy was and is medically indicated for this particular patient. Continued treatment with frequent observations and measures to determine clinical progress is medically appropriate. The patient should be re-evaluated after three months to determine if there has been continued clinical improvement; if there is documented evidence of progress, the therapy should continue.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast MRI. There is a lack of peer-reviewed literature supporting the use of screening breast MRI in a patient with a calculated lifetime risk of cancer of less than 20%. In this case, the abnormal results of the thermal breast imaging study do not, in and of themselves, indicate the need for a breast MRI study. The patient is refusing the standard screening evaluation of mammography. If the patient had screening mammography that showed dense breasts with suspicious findings, however, an MRI would be an appropriate test. On the basis of her medical records, history, and prior breast imaging studies (particularly the lack of any mammograms), screening breast MRI is not medically necessary for the patient at this time.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 radiology, with a primary specialty certificate in diagnostic radiology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the intensity modulated radiation therapy (IMRT) for treatment of the enrollees rectal adenocarcinoma. Findings:  The physician reviewer found that currently, there is a lack of clinical data in the medical literature to demonstrate that treatment with IMRT offers a clinical benefit compared to conventional radiation therapy techniques for patients with rectal cancer. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using three-dimensional (3D) conformal radiation. The plan comparison submitted by the provider shows no clinically significant difference between standard 3D conformal planning and the IMRT plan. In addition, the National Comprehensive Cancer Network (NCCN) guidelines indicate that IMRT should not be done for patients with rectal cancer because a recent phase II study examining this issue did not reveal positive health outcomes. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued acute care services. In this case, the records noted that the patient reported ongoing chronic abdominal pain.  She was previously noted to have opiate dependence. Her vital signs were stable, and she was afebrile. An abdominal examination was benign with a functioning gastrostomy-jejunostomy tube. She was at her baseline mental status. The records did not document active infection, acutely abnormal laboratory values, or significant electrolyte disturbances. The plan of care included podiatry follow-up for toe pain, continuation of anti-seizure medications, as she was medically stable on the current dosage, and continued enteral nutrition using the gastrostomy-jejunostomy tube. She was receiving physical therapy, able to perform bed mobility, transfers, and gait training up to 200 feet with auxiliary crutches. In this clinical setting, given that the patient was and is medically stable and able to receive continued care at a lower level of intensity, the services at issue were not and are not medically indicated. Therefore, continued acute care services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer 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 internal 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.