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

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees mixed receptive/expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Feldman & Messick). A meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than children who have no treatment. The documentation demonstrates that this patient was noted to have speech and language delay at 24 and 28 months of age. A subsequent evaluation at 29 months of age did not reveal a delay; however, different tools were utilized to determine the patients abilities. It is important to determine this patients current speech and language development. Given the discrepancy in the findings of the patients speech and language evaluations, he should undergo re-evaluation with an independent speech therapist to determine his current level of functioning.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory tests received for evaluation of the enrollees family history of rhizomelic chondrodysplasia punctate 1 (RCDP1). Findings:  Three physician reviewers have found that RCDP1 is a condition that impairs the normal development of many parts of the body. The major features of this disorder include skeletal abnormalities, joint deformities, distinctive facial features, intellectual disability, respiratory problems, cataracts, cardiac anomalies, cryptorchidism and seizures. Because of their severe health problems, most people with rhizomelic chondrodysplasia punctata survive only into childhood. However, a few individuals with milder features of the condition have lived into adulthood (Cim, et al; Duker, et al). Prenatal diagnosis of RCDP1 has tremendous clinical benefit. Early detection in pregnancy allows for the appropriate care team to be in place at the time of delivery. This care team would include orthopedic surgery, ophthalmology, neonatal intensivists, pediatric surgery and pediatric neurology. Early diagnosis of RCDP1 allows for the appropriate healthcare team to be in place at the time of delivery in order to address the multiple congenital complications present. Therefore, laboratory tests received were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three physician reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Two reviewers are board certified in pediatrics and clinical genetics and are actively practicing. One reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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

A 75-year-old male enrollee has requested Cialis 5mg, daily, and Viagra 100mg, every other day for treatment of his status post radical prostatectomy.  Findings:  The physician reviewer found that erectile dysfunction is a condition that is often affected by multiple factors.  Treatment with oral agents, including Viagra or Cialis, has been demonstrated to be helpful to some patients. In this patients case, the provider has recommended aggressive erectile dysfunction rehab therapy. Erectile dysfunction is often seen after a radical prostatectomy, and the goal of penile rehabilitation is to return to baseline erections or improvement in the postoperative impotency that may occur.  The concept of penile rehabilitation is not proven at this time.  The current medical evidence does not support the use of Cialis 5mg, daily, and Viagra 100mg, every other day for the treatment of this patient. All told, the medications at issue were not and are not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that regarding the medical necessity of speech therapy for the treatment of this patient with autistic spectrum disorder (ASD), these services are medically necessary based on overall evaluation of the literature. An additional point with regard to this patients case is that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development that is seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that based on the available documentation, the RTC services were not medically necessary for treatment of this patients medical condition. The patient was not a danger to himself or others. He was not manic, psychotic, agitated, or showing impulsivity. In addition, he was not gravely disabled, he was cognitively intact, and he was medically stable. He was psychiatrically stable such that he could have been managed at outpatient level of care. There had been no medication changes for at least one week. He was cooperative and engaged in all aspects of his treatment. His wife was supportive. The overarching themes he was dealing with were basically long-term issues which are traditionally dealt with on an outpatient basis. He did not require 24-hour supervision. All told, the patient was a candidate for treatment at a less restrictive level of care and did not require RTC services. 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 psychiatry with sub-specialty certification in addiction 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

A 37-year-old male enrollee requested surgical resection of small intestine carcinoma for medical treatment of his small intestine cancer.  Findings:  The physician reviewer found that the request for surgical resection of small intestine carcinoma is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is 37-years-old and has advanced recurrent cancer. Modalities such as chemotherapy and radiation have not been shown to be beneficial in this setting (Higashi, et al). Further, as noted above, the patients oncologist indicates his tumor is not chemo-sensitive, further limiting the potential benefit of chemotherapy. Surgical intervention is the only treatment option that is likely to be palliative if not curative. In sum, given the lack of available treatment options in this setting, the requested procedure is medically reasonable and necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for treatment of the enrollees autism. Findings:  The physician reviewer found that severe functional impairment is present, which includes head butting, aggression, anxiety, frequent tantrums, no eye contact, poor safety awareness and poor communication. Per Posey and McDougle, children who have autism spectrum disorder benefit from intensive early intervention. This patient is receiving specialized multidisciplinary services through a partial hospitalization program for autism spectrum disorder. He is beginning to sign for preferred objects with minimal prompting. The patient has mastered his first imitation task and has progressed to a second one. The Child and Adolescent Level of Care Utilization System guidelines support this level of care given the severity of the patients functional impairment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing provided on dates A, B & C.  Findings:  The physician reviewer found that the Guardant360 gene testing provided on date A and C were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the medical literature supporting the use of liquid biopsy to guide a patients therapeutic plan in addition to standard of care practices such as clinical, laboratory, and radiographic evaluations. However, there is a lack of documentation supporting the gene testing performed on date B. The records do not support rationale as to the role of the repeat Guardant360 gene testing performed one month after the initial test. In sum, the testing performed on date A and date C were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 a positron emission tomography (PET) scan for evaluation of his medical condition. Three physician reviewers found that the medical records note a history of cognitive impairment post-concussion and acute myocardial infarction with hypotension. There is no recorded history of progressive cognitive decline, hallucinations, or extrapyramidal features.  The described clinical features do not suggest Alzheimers disease or frontotemporal dementia.  Cognitive impairment following cardiac events and hypotension may be permanent, and is not typically progressive.  In this patients case, there is no indication for a PET scan, and a lack of evidence indicating that findings from a PET scan would alter therapy.  All told, the requested PET scan is not likely to be more effective than other methods of evaluating this patient.  Final Result:  Three 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 reviewers are board certified in neurology 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: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested reimbursement for Oncotype DX breast cancer assay for an evaluation of her breast cancer. Findings:  The physician reviewer found that the Oncotype DX breast cancer assays greatest utility is in indicating whether an individual patient falls into the low risk category, for which hormone therapy alone may be sufficient, or the high-risk category, for which chemotherapy followed by hormone therapy is probably indicated. Among medical experts, there is not unanimity of opinion on whether the Oncotype DX assay should be routinely applied in this setting. The National Cancer Comprehensive Network recommends Oncotype DX breast cancer assay for hormone receptor positive, lymph node negative, Her-2 non-overexpressed tumors larger than 0.5 cm to further refine risk stratification for adjuvant chemotherapy. The American Society of Clinical Oncology has recommended the use of this testing in early stage breast cancer patients who wish to decide on the use of chemotherapy. However, there is acceptance among experts of the validity of this testing and the applicability of results in patients with low recurrence and high recurrence scores. Approximately 20 percent of lymph nodes in which no tumor is identified after routine processing and hematoxylin and eosin examination contain tumor cells that can be identified by serial sectioning or immunohistochemistry. These are termed occult metastases. In approximately 10 percent of cases, the foci will be less than 2 mm in diameter (micrometastases). The prognostic implication of identifying these micrometastases, in particular whether conversion to a higher disease stage is clinically relevant, is uncertain. Patients with micrometastatic lymph nodes are treated similar to patients with negative lymph nodes in clinical practice. Given that this patient had lymph node micrometastases, Oncotype DX breast cancer assay was medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee has requested for detoxification treatment for treatment of his opioid dependence. Findings:  The physician reviewer found that the reference discusses the efficacy and safety of using Suboxone in patients with opioid and cocaine dependence in an outpatient setting, at doses up to 16mg per day (which exceeds the dose this patient was taking). Suboxone was developed and FDA approved for use in the outpatient setting for this indication.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 60-year-old female with cystic fibrosis. She has had a bilateral lung transplant for which she will require lifelong immunosuppression and probable steroid treatment. She was found to have worsening osteopenia, a problem typically seen in cystic fibrosis patients because of malabsorption of calcium or vitamin D, potentially complicated by steroid treatment.The provided records are not entirely clear, but it appears that her DEXA scan results gradually worsened through October 2004 despite taking Fosamax. She was then switched from Fosamax to IV pamidronate every three months, and the DEXA scan performed in December 2005 shows improved results at the left hip and lumbar spine. The patient has requested authorization and coverage for continued IV pamidronate, which the Health Plan has denied.The patient has cystic fibrosis, historically associated with osteoporosis related to malabsorption of calcium and/or vitamin D. She also has had a bilateral lung transplant requiring long-term treatment with immunosuppressives and steroids, further increasing her risk for bone loss. She has already been shown to have worsening osteopenia while taking Fosamax, and has further demonstrated improved DEXA results only after switching to IV pamidronate. The submitted literature includes reports of IV pamidronate being as effective as oral bisphosphonates in patients unable to use oral agents. Supporting letter from the patients cystic fibrosis clinic notes the use of IV pamidronate to be an accepted part of the protocol in cystic fibrosis clinics.In conclusion, the patient has a continuing and significant risk for bone loss, has already failed Fosamax, and has demonstrated a beneficial response to IV pamidronate. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 74-year-old female enrollee requested authorization and coverage for L4-5 posterior decompression, fusion, and instrumentation with iliac crest bone graft for treatment of back pain.  The health plan denied the enrollees request indicating that the requested surgery it is not medically necessary.Once physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis that was performed. Findings:  The physician reviewer found that the patient had a digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. 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: the 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sleeve gastrectomy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of morbid obesity and underwent Lap-band surgery.  This needed to be emergently removed secondary to complication of slipped band. The Lap-band, unlike other metabolic bariatric procedures is a foreign body and when removed no longer leaves any permanent tool for weight loss.  Therefore, the natural history is that these patients may ultimately regain weight without a more durable metabolic bariatric procedure.  In this patients case, her body mass index is slightly under 35, and she has hypertension.  However, proceeding with the sleeve gastrectomy cannot be recommended at this time.  The records do not document an updated dietary clearance to ensure that this patient understands the dietary consequences and risks and is considered behaviorally to be aware of the risks and determined to be an appropriate candidate.  Standard primary guidelines for bariatric surgery recommend a complete thorough multidisciplinary evaluation including dietary clearance.  In sum, the requested sleeve gastrectomy is not medically indicated for the 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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Repatha SureClick injections. The American College of Cardiology (ACC) has developed an expert consensus decision pathway regarding the role of non-statin therapies for low density lipoprotein (LDL) cholesterol lowering for management of atherosclerotic cardiovascular disease risk (Lloyd-Jones, et al.). Per the ACC guidelines, Repatha may be considered when the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia. The records provided for review do not include documentation that the patient has been unable to achieve an LDL goal of less than 70 mg/dL while on a statin plus ezetimibe. Therefore, the requested Repatha SureClick injections are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.