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

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that despite the enrollee's diagnosis of autism, this patient has the potential to communicate. He has developed rudimentary signing skills and his receptive language was found to be at 19 months when his chronological age was 31 months.  Thus, he does have the intellect to develop speech, albeit at a slow skill level.  An in plan therapist has recommended speech therapy, however, the Health Plan cites the paper by Meyers, et al. as supporting their position that there is not demonstrable oral pharyngeal pathology. This report is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children.  Specifically, the authors state People with [Autism Spectrum Disorder] ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. The paper by Turner is a controlled study comparing autistic children who did and did not receive speech therapy.  Those who did receive therapy had far greater communication skills than children who did not receive speech therapy. The report from the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. Thus, in accordance with the peer-reviewed medical literature, speech therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested a 12-week course of Sovaldi 400 mg in combination with ribavirin 600 mg for medical treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that at this time there is a lack of clinical documentation that shows the patient has significant liver disease. The clinical documentation provided shows no evidence of an assessment of the degree of liver fibrosis. Moreover, the value of treatment is unclear in individuals with minimal or no fibrosis with respect to long-term outcomes. In sum, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi 400 mg in combination with ribavirin 600 mg is not medically necessary. Therefore, the medical necessity of the requested medication combination has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: the physician reviewers are 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for opioid pain medication and/or cesarean section to be performed sooner than already scheduled. The records provided for review document that this patient has been scheduled for a repeat cesarean delivery in the setting of two prior cesarean sections. The patient has requested earlier delivery due to her worsening pain. Per the available documentation, the patients pain appears to be musculoskeletal in origin in a setting of known osteoarthritis and groin discomfort that is impacting her ability to ambulate. She reports having experienced this pain in prior pregnancies with resolution after delivery. She has been evaluated in the labor and delivery suite for this pain and has been discharged home with over-the-counter medication and outpatient follow-up. There is no clinical documentation to support any other maternal or fetal indications for her pain. The timing of cesarean section delivery prior to her scheduled date requires documentation of a clinical indication when the benefit of earlier delivery outweighs potential risk. Based on this patients records, there is a lack of clinical documentation to support an earlier delivery than on the already scheduled date. In terms of the patients pain, there is inadequate clinical documentation to support an indication for treatment with opioid medication. The risk-to-benefit ratio of opioid use in pregnancy has been established in the peer-reviewed medical literature. The studies report that opioids should only be used after non-opioid treatment has been tried and failed. The available records do not support the use of opioids for treatment of this patients chronic pain during pregnancy or that non-opioid therapy has been exhausted. Therefore, the requested opioid treatment is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female has requested an electroencephalogram (EEG) procedure for evaluation of her condition prior to hysterectomy.  Findings:  The physician reviewer found that there is no current medical indication to perform an EEG in this case. There is nothing in the patients history, CT scan, MRI study, or examination that suggests a need for an EEG, nor is there any reason to hold off on surgery on this basis. The recommendation to perform an EEG appears unjustified and is not pertinent to the patients current medical issues.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients composite score is consistent with medically monitored residence based services, such as RTC. Given these findings, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in child and adolescent 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

The patient is a 64-year-old man who has had a rising PSA since 1999, which has become 6.5 with a free PSA of 12.3% in March 2004. In March 2004, his urologist performed prostate biopsies and Gleason score of 6 (3+3) was found on both sides of the prostate. There was 60% involvement on the right and 30% involvement of the biopsied specimen on the left. His clinical stage by the urologist was T2b. In addition, he had severe urinary obstruction. In July 2004, the patient was placed on Lupron. He was also told that because of his severe urinary obstruction, I-125 brachytherapy or HDR were not optimal for his tumor.  On 9/8/04, he underwent laser TURP. The patients symptoms were relieved. IMRT was recommended primarily because of the patients urinary obstruction. The Health Plan has denied coverage for IMRT on the basis it is not medically necessary for treatment of the patients medical condition.This patient has a PSA of 6.5, Gleason of 6 and T2b prostate cancer. Based on Partins Tables, his chance of having a confined tumor to the prostate is 48%. He has a 45% chance of capsular involvement, a 5% chance of seminal vesicle involvement, and a 3% chance of lymph node involvement. Additionally, based on the biopsies he has 60% involvement by tumor on the right side and 30% on the left. This is a substantial volume of tumor. Lupron has a 75% chance to reduce the volume of the tumor. Based upon the information provided it does not appear that the patient has a significant urinary obstruction at this time. As such, HDR is a better form of conformal therapy for the patients prostate cancer in combination with external beam to his pelvis. IMRT dose is planned for 75.2Gy while HDR plus external beam physical dose is 70 Gy with a biological dose in excess of 100 Gy. As such, IMRT is not the most appropriate treatment for this patients cancer.Based upon the information set forth above, 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cooled radiotherapy for the right knee. Based on the available documentation, this patient presents with chronic superomedial pain in the right knee for at least one year. She complains of sharp pain exacerbated by climbing stairs. Additionally, she has Graves disease and asthma. She has reportedly failed conservative treatment, including acetaminophen, NSAIDs, physical therapy, and corticosteroid injections, which yielded 50% relief. A review of the current medical literature with regard to genicular nerve radiofrequency ablation indicates that it has been used for pain relief and improvement of function in symptomatic individuals with knee osteoarthritis who are not candidates for surgery or have undergone surgery and have persisting pain. Optimal candidates have moderate to severe osteoarthritis (Kellgren-Lawrence grade 3 or 4), for which surgery might be considered, and patients who are not good surgical candidates because of medical comorbidities and/or a high body mass index (BMI). In this case, there are no radiographic reports on which to determine if grade 3 or 4 Kellgren-Lawrence moderate to severe osteoarthritis signs are present (osteophytes, joint narrowing or bone sclerosis). Further, the patient does not have significant comorbidities, such as abnormal BMI, that would limit surgical options. Based on these considerations, cooled radiotherapy for the right knee is not likely to be more beneficial than other available standard treatments. Findings:  Three of the three physician reviewers found the requested cooled radiotherapy for the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested twice weekly therapy visits for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the medical literature does not define the frequency or duration for the amount of psychotherapy required for each patient. However, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature also supports that in unrestricted therapies, each additional psychotherapy session has a diminished effect. An article by colleagues, they report, Our findings suggest that, at least in unrestricted therapies, the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. These results are consistent with previous studies. Given this information, the patient has been stable, and her symptoms of social isolation and social anxiety have improved. She has been sober from alcohol for several years. It appears from the documentation that the patient is mentally stable and not in an acute crisis. In this patients case, her chronic problems can be addressed during a weekly psychotherapy basis. It is also important to note that biweekly psychotherapy sessions in general are not common practice unless one is undergoing intense evidenced based treatment protocols such as prolonged exposure therapy or dialectical behavioral therapy. Even with these protocols, biweekly treatments are time limited. Given this information, the patients records do not support biweekly psychotherapy sessions. Therefore, twice weekly therapy visits are not medically necessary for 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 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: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested PET scan with CT attenuation for evaluation of her metastatic parosteal osteosarcoma. Findings:  Three physician reviewers found that in this case, the diagnostic procedure at issue was likely to have been more efficacious for evaluation for tumor recurrence or additional metastases as compared to other tools for evaluating this patient.  In this clinical scenario, the PET scan with CT attenuation would have impacted treatment planning.  The current medical evidence supports the diagnostic procedure in this clinical situation.  All told, the PET scan with CT attenuation provided was likely to have been of greater benefit than other available methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for FoundationOne CDx genomic testing. Adenocarcinoma of the esophagus that has metastasized carries a poor prognosis. Next-generation sequencing (NGS) offers the opportunity to assess numerous mutations simultaneously, along with other molecular events such as amplification, deletions, tumor mutation burden, and microsatellite instability (MSI) status. The U.S. Food and Drug Administration (FDA) approves the use of several targeted therapeutic agents, including trastuzumab, pembrolizumab/nivolumab, for the treatment of esophageal and esophagogastric junction cancers. The National Comprehensive Cancer Network (NCCN) guidelines for esophageal and esophagogastric junction cancers recommend the use of NGS for locally advanced esophageal cancer. In this case, a pathology report reported that the patient is HER2 negative. In this clinical setting, the NCCN guidelines support the use of NGS comprehensive testing to look for targets for which newer treatments may be available and for evaluation for clinical trials. Therefore, FoundationOne CDx genomic testing is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested FoundationOne CDx genomic testing 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 service is 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 internal medicine with sub-specialty certifications in medical oncology and in hematology 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 has requested authorization and coverage for continuous passive motion (CPM). Researchers concluded that both CPM and conventional physical therapy are beneficial for the treatment of adhesive capsulitis in diabetic patients. However, the authors found that CPM provided distinctive improvements in the function and pain levels of adhesive capsulitis patients. This patient was diagnosed with left shoulder adhesive capsulitis. Clinical examination findings documented significant preoperative loss of left shoulder range of motion that has failed to respond to medications, injections, physical therapy, and home exercise. She underwent left shoulder manipulation under anesthesia and capsular release. The provider has recommended use of a postoperative CPM unit, which is consistent with the current evidence-based medical literature and guidelines for the treatment of moderate to severe adhesive capsulitis to restore shoulder functional mobility. Given this support, the requested CPM is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested reimbursement for one day of hospitalization to treat back pain.  The Health Plan denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who is status post decompressive laminectomy L4-L5, bilateral foraminotomies.  Findings:  The physician reviewer found that the submitted documentation failed to establish the medical necessity of the services at issue.  The development of screening criteria for review of patient care has resulted in the use of several generally accepted systems for use as screening tools.  In this patients case, she did not meet InterQual criteria for acute inpatient level of care.  The medical records indicate that the patient was ambulatory and was on oral analgesic medications on the date of service at issue.  All drains and catheters had been removed.  The submitted clinical records do not demonstrate any clinical situation which would have required inpatient level of care.  All told, the one day of hospitalization was not medically indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for speech therapy services provided in the Armenian language without the use of a translator twice a week. Bilingual or multilingual children have critical periods of brain development that allow them to learn language in a different fashion than adults. In addition, bilingual children that have primary problems with speech fluency, the most effective remediation of these problems is active, ongoing speech and language therapy. In this patients case, his primary speech therapist has documented an ongoing need for services and his progress with this intervention. Speech therapy in the Armenian language is appropriate since the patient lives in a bilingual household and needs to communicate in both languages to perform his activities of daily living. All told, speech therapy services provided in the Armenian language without the use of a translator twice a week are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.