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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) of the right breast. IORT with accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. APBI may be delivered using external beam radiotherapy, brachytherapy, or IORT. For APBI delivered using IORT, there is a phase III randomized data of over 3400 patients supporting its use that reported equivalent four-year local control rates between IORT and external beam whole breast radiotherapy. Available data includes 8.6-year follow-up results that continue to show non-inferiority with regards to local recurrence-free survival, mastectomy-free survival, and distant disease-free survival. All told, the requested IORT of the right breast is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IORT of the right breast is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin.Findings: Standard of care for evaluation of short stature in a prepubertal girl includes magnetic resonance imaging (MRI) with and without contrast of the pituitary and hypothalamic anatomy to exclude a lesion as well as circulating karyotype to exclude Turner syndrome. The submitted records do not document that an MRI with and without contrast of the pituitary and hypothalamic anatomy was performed, so sufficient diagnostic criteria for an FDA-approved indication for growth hormone (GH) therapy have not yet been met. The FDA-approved indications for somatotropin include growth hormone deficiency and idiopathic short stature. The current medical evidence does not support the requested medication in this clinical setting. Therefore, Nutropin AQ Nuspin is not medically necessary for the treatment of the patients medical condition.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 pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested laparoscopic Roux-en-Y bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient has clinically severe obesity and has failed prior weight loss attempts. She completed a thorough multidisciplinary evaluation that did not reveal any obvious psychological, dietary or medical barriers to surgery. The patient meets all generally accepted guidelines for bariatric surgery, including National Institutes of Health consensus guidelines. The current medical evidence supports weight loss surgery in this clinical scenario.  This patient has failed dietary efforts that span over the past several years.  All told, the requested laparoscopic Roux-en-Y bariatric surgery is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  speech therapy, twice per week for one hour per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in the clinical literature, Shevell evaluated patients under five years of age who were referred over an 18-month period to subspecialty services for initial evaluation of a suspected developmental delay. Of these patients, 99 were found to have global developmental delay with 96% showing evidence of a mild or moderate delay. An etiologic diagnosis was determined in 44 patients and the authors concluded that an etiologic diagnosis is often possible in the young child with global developmental delay, particularly in the absence of autistic features. The patient in this case does not have any evidence of autism. However, the In-Plan provider did not attempt to look for an etiology of this patients speech delay. Similarly, the American Academy of Neurology (AAN) practice parameters recommend evaluation of a patient with non-progressive global delay as a specific etiology can be determined in the majority of these children. Certain routine screening tests are indicated and depending on history and examination findings, additional specific testing may be performed, which were not conducted in this patients evaluation. The goal of the evaluation is to assess the patients speech and language function relative to age and developmental expectations. When therapy is recommended, the primary goal is to give the patient a reliable way to exchange ideas and information in his daily social and educational environment. Treatment is tailored to the specific communication needs of each child, which vary with disorder type and severity, the patients age, and the etiology of the problem. Any speech or language intervention requires that the patients family and educators be involved to provide ongoing support for the patient outside of the clinical setting. Thus, speech therapy is within the standard of care for patients with speech delay of unknown etiology. Given this patients deficits, it is medically necessary for this patient to receive the requested speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying LOCUS, this patient met the criteria for prior RTC services for five days of treatment. The patient has been at low risk of harm (score 1) as there are no reports of suicidal ideation or safety concerns. The patients functional status has been moderately impaired (score 3). The patient has taken a leave from college and has become socially isolated. The records document that the patient has minor comorbidities (score 2), including bradycardia as a result of her food restricting, which has resolved with treatment. The patients recovery environment is minimally stressful (score 2). Her family is supportive, but she has limited social support. The patients recovery environment is supportive (score 2). The patient has an outpatient therapist and psychiatrist. The patient has demonstrated moderate response to treatment (score 3). The patient has been gaining weight and has been described as constructive in treatment (score 2). This gives the patient a composite score of 15, which is consistent with low intensity community based services. Overall, the records document that the patient became stable for transition to a lower level of care. Therefore, the RTC services were medically necessary, while future RTC services are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Xiaflex for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Peyronies disease is caused by scar tissue which forms along the length of the penis in the corpora cavernosa.  Depending on the severity of the condition, this can cause penile curvature with erection.  The curvature can make intercourse difficult and/or painful for the patient and his partner.  Potential treatment options for Peyronies disease include surgery, minimally invasive treatment options, and medications. The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  Per the medical evidence, the options which have the potential to significantly reduce penile curvature in this patient are Xiaflex injections and reconstructive surgical therapy.  There is sufficient support for the use of Xiaflex in this clinical setting.  All told, Xiaflex is medically indicated for the 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 urology 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 parent of an enrollee has requested authorization and coverage for relationship development intervention (RDI) therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature supporting the request for RDI therapy as medically necessary for treatment of the patients medical condition. RDI is a parent-based, cognitive-developmental approach, in which primary caregivers are trained to provide daily opportunities for successful functioning in increasingly challenging dynamic systems. However, the research supporting RDI is limited. Moreover, ABA therapy is the standard of care for children with autism spectrum disorder and has sufficient research supporting its use. In sum, there is a lack of adequate research supporting RDI therapy as medically necessary for the treatment of the patients autism spectrum disorder. 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested temazepam, Ambien, Klonopin, fentanyl, Norco, and Adderall for the treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  Short release/acting opioids, such as Norco, are associated with a high risk of dependence and tolerance.  Researchers reported that high-dose and short-acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Researcehrs also reported that prolonged use of high-dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity.  All told, the requested temazepam, Ambien, Klonopin, fentanyl, Norco, and Adderall are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Synvisc injections for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. The evidence based literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with severe osteoarthritis of both knees. He has undergone two prior viscosupplementation series with positive results documented in terms of pain reduction, improved function, and reduced medication use. He is currently reporting progressively worsening and function-limiting knee pain. Therefore, the requested Synvisc injections are medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home infusions of Privigen 10%, 190 grams infused over three days every four weeks for three cycles. Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to control the pain. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. IVIG is supported as a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. IVIG has been used with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber polyneuropathies. In a retrospective study by researchers, 55 patients with confirmed small fiber polyneuropathy attributed to autoimmunity received IVIG for more than three months. The authors reported that 74% of patients rated themselves as improved, treating providers labeled 77% of patients as IVIG responders, and 16% of patients entered remissions that were sustained after the completion of IVIG. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected small fiber polyneuropathy patients with apparent autoimmune causality. In this case, the patient has debilitating small fiber neuropathy with laboratory evidence of autoimmunity. He has been treated with conventional medical therapy without substantial improvement. Based on the current peer-reviewed medical literature, patients with autoimmune small fiber neuropathy may improve clinically with IVIG. Accordingly, the requested home infusions of Privigen 10%, 190 grams infused over three days every four weeks for three cycles is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested home infusions of Privigen 10%, 190 grams infused over three days every four weeks for three cycles is 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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

A 53-year-old male enrollee has requested refractive laser surgery on the right eye for the treatment of his acquired astigmatism. Findings:  Three physician reviewers found that this patient has had a very serious condition requiring a corneal transplant many years ago. No one knows how long corneal transplants will last. Refractive laser surgery is reported to help with correction of large degrees of anisometropia.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of the left side of the colon with a low ileorectal anastomosis with lysis of adhesions. Findings:  The physician reviewer found that the available documentation, the requested completion colectomy and ileorectal anastomosis is not medically necessary for treatment of this patient. The patients complaint of pelvic pain along with clustering of the sitz markers in the rectosigmoid area are concerning for obstructed defecation. This suggests that the patients problem may be due to the ability of the rectum to empty rather than the presence of the sigmoid colon. The patient requires further motility work-up as recommended by her provider, which may include studies such as anorectal manometry and magnetic resonance imaging (MRI) defecography. In the absence of data from these studies, the requested surgery is not supported by the medical literature. Therefore, the requested removal of the left side of the colon with a low ileorectal anastomosis with lysis of adhesions is not medically necessary for treatment of this patient.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 surgery with subspecialty certification in colon and rectal surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a six-year-old male enrollee have requested authorization for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that medically necessary therapy requires medical oversight and clearly identified functional goals. In reviewing the documentation from the earlier speech therapy, educational goals are not clearly distinguished from functional goals. An additional concern is the lack of physician involvement. When therapy is continued for an extended period as it has been in this instance, it must be physician-directed to insure adequate progress is being achieved. The patients functional status should be assessed at regular intervals by a qualified physician for appropriate decision-making with regard to the course of the therapy. The physician should also ensure the goals of the therapy address community based/functional issues.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested Proton Beam Radiation therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that this patient has a low volume, low grade and a low PSA prostate cancer. Practically any form of radiation therapy will offer him a good chance of tumor control. He has coverage for IMRT which provides as good local control as proton beam. In summary, the patient has low volume of cancer in his prostate.  Proton beam radiation therapy is not superior in cure rates, survival rates or side effects to normal tissues as compared to IMRT.