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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for speech and language therapy. A review of the records indicates the enrollee was diagnosed with speech delay, specifically developmental expressive language disorder after an Early Intervention in-home evaluation. At the time of evaluation, he was not saying any words and was communicating through gestures and vocalizations. At the end of the evaluation, the impression was that the enrollee had a significant delay in his language expression skills. His hearing is normal and his social skills are also normal for age. Speech and language intervention was recommended with the goal of being able to communicate his wants and needs, add 50 new words to his vocabulary and begin to use 2 and 3-word phrases. The enrollee was assessed using an accepted behavioral assessment battery of language development specifically for his age group.  (Rosetti) The Rosetti assesses a variety of language and developmental skills, including social skills, attachment, play, expressive and receptive language skills.  The enrollee was able to participate in all parts of testing and performed at age-appropriate levels in all areas with the exception of expressive language, in which he was shown to be at the 9-12 month range.  This represents a 6-9 month delay, which is significant.  Expressive language disorder is categorized as a disability, and without intervention has been linked to issues with literacy /emerging reading skills.  At this point, the enrollee can only express his wants/needs by gesture and facial expression.  As his thoughts and needs become more complex, this will become even more inadequate as a form of primary communication.  Given his overall development, he has good prognosis to bring his language skills to age-appropriate levels with a skills speech-language pathologist.  Final Result: The reviewer determined that the requested speech and language therapy is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in Speech-Language Pathologyand 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization treatment for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support the services at issue in this clinical setting.  This patient has completed courses of partial hospitalization and presented with a familiar symptom complex.  Thus, the expectation for enduring improvement and prevention of a more serious episode with another iteration of partial hospitalization is dubious.  Further, the clinical documentation does not demonstrate that a subsequent well-organized and comprehensive outpatient plan had been unsuccessful following the most recent discharge from partial.  In this patients case, there is no evidence that a multidisciplinary intensive outpatient plan including daily group therapies with community psychosocial support programming coupled with case management services, suicide prevention safety planning, psychiatric visits and individual therapy sessions would have been insufficient.  Based on the relevant peer-reviewed literature and documentation provided, partial hospitalization treatment was not and is not medically indicated 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRTfor treatment of the enrollees uterine cancer. .Findings:  Three physician reviewers found that upon review of available data, IMRT is likely more beneficial in treating this patients endometrial cancer than standard therapy consisting of three-dimensional conformal radiotherapy (3DCRT). Chen and colleagues reported that the main areas where IMRT benefits patients is decreased gastrointestinal toxicity and decreased marrow toxicity. For marrow toxicity, a multi-institutional phase II trial showed that bone marrow toxicity could be decreased with the appropriate IMRT planning parameters (Klopp, et al). Based on this support, the requested IMRT has a substantial advantage over 3DCRT in the treatment of endometrial cancer. Further, based on the improved side effect profile and potential impact on the patients ability to undergo full-dose chemotherapy, IMRT should be considered standard therapy versus 3DCRT. Accordingly, IMRT 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld

The parent of a nine-year-old female enrollee requested genotype testing (CPT codes 81225, 81226, 81227, 81291 and 81479) for medical evaluation of the enrollees anxiety disorder.  Findings:  Three physician reviewers found that In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on a patients genetic organization, may become a valuable tool in the treatment armamentarium for those plagued with mental illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  At this time, there is a lack of adequately powered studies illustrating consistent and reproducible results for the disputed service.  Additionally, in this case, there is a dearth of case-specific information detailing psychosocial stressors or the outcomes of past interventions such as the specific type, setting and duration of psychotherapy, community activities, and the dosing and duration of treatment for psychotropic medications.  All told, the superior efficacy of genotype testing has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested continued skilled nursing facility care including physical therapy and occupational therapy for treatment of her medical condition status post motor vehicle accident Findings:  The physician reviewer found that in applying the skilled nursing care facility services guidelines recommended by Goroll and Mulley, continued SNF services were not medically necessary as of the date in question. The patients post-operative course was uneventful and she was transferred to a SNF to receive skilled level of care nursing and therapy services. She received physical and occupational therapy. Per the providers notations, the patient was unable to tolerate sitting, standing, or any weight bearing. A few days later, she was on minimal assistance with bed rails, supine position, scooting, and able to ambulate to a wheelchair, but remained non-weight bearing. The submitted documentation indicates the patient was stable on her medical regimen with adequate pain control with oral medications, was tolerating an oral diet and had no complex wound care issues. The attending provider indicated that the patient was stable for discharge one week prior to the date in question, with home services including physical therapy and a medical social worker. A review of the patients medical records has revealed that there was no indication for continued skilled level of care nursing services from the date in question forward. Per the Centers for Medicare & Medicaid Services (CMS) criteria for skilled nursing care, the patient did not meet established criteria for continued skilled services. She did not require treatment in a skilled nursing or rehabilitation center with staff to manage, observe and evaluate her care. She was stable on her medical regimen and per her attending provider, had met the goals for short-term rehabilitation. Her status was continued non-weight bearing and she was stable for discharge home with services to include physical therapy and a medical social worker.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee requested authorization and coverage of Peg-Intron for the treatment of hepatitis C.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 23-year-old male enrollee has requested LINX Reflux Management System for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that this patient is more likely to benefit from the requested LINX procedure over standard treatment consisting of fundoplication. The patients physical history and clinical findings support an indication for either procedure. However, he has the presence of Barretts at a young age. There is concern that if he undergoes fundoplication, then surveillance for dysplasia would not be possible. All told, the requested LINX procedure is likely to provide this patient with an improved health outcome as compared to standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the LINX anti-reflux procedure for medical treatment of her gastroesophageal reflux disease.  Findings:  Two physician reviewers found that In this patients case, the superior efficacy of the requested services has not been established.  The LINX Reflux Management System has been approved for lower esophageal sphincter augmentation for patients with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Per the current medical evidence, results from early studies at four years are encouraging.  However, the long-term durability has not been assessed.  Anti-reflux surgery is designed to provide benefit for many years, and this has not been demonstrated. Moreover, there is a lack of controlled data comparing this technology to continued proton pump inhibitor therapy or fundoplication.  All told, the requested LINX anti-reflux procedure is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, genotype 1 patients who have failed PEG-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Afdhal, et al; Lawitz et al). The patient is ineligible for any alternatives containing PEG-interferon and ribavirin due to a pre-existing medical condition, which can be exacerbated by either medication. For these reasons, the requested treatment with Harvoni supported as medically necessary for the treatment of this patients hepatitis C infection. 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 internal medicine with sub-specialty certification in gastroenterology 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: Upheld

The parent of an 11-year-old female enrollee has requested growth hormone therapy, Nordiflex 1.5mg daily injections for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the submitted medical records do not document this patients birth weight, growth curves charts and clinical lab workup data. As such, the information provided does not demonstrate an improvement in growth velocity as a result of GH therapy. Nor do the records document the patients failure to catch-up in growth by two years of age; thus, the diagnosis of small for gestational age cannot be validated based on the information provided. In addition, there is no definitive scientific literature which supports combination therapy for short stature and pubertal suppression. Therefore, there is inadequate clinical and scientific evidence demonstrating that the proposed therapy is likely to result in an improved outcome in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tramadol 50 mg. Per the Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines, providers should continue opioid therapy when there is adequate documentation that there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Further, the CDC recommends that if benefits do not outweigh harms of continued opioid therapy, providers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. This patients records do not include evidence of significant objective and measurable functional improvement on prior Tramadol. The records lack documentation that the patient has failed non-opioid pharmacologic approaches used for pain include analgesics such as acetaminophen, NSAIDs, and cyclooxygenase 2 (COX-2) inhibitors, selected anticonvulsants, and selected antidepressants. Moreover, there is no documentation that the patient has failed cognitive behavioral therapy (CBT), exercise therapy, interventional treatments, and multimodal pain treatment) and non-opioid pharmacologic treatments for chronic pain. All told, Tramadol 50 mg is not medically necessary for treatment of this patients medical condition. 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. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab. Treatment for autoimmune autonomic ganglionopathy (AAG) is complicated due to its rarity. Mckeon and Benarroch note that AAG is a peripheral autoimmune autonomic disorder that manifests with acute or subacute onset of generalized or selective autonomic failure. The authors further note that recognition of an autoimmune basis for autonomic disorders is important as they have the potential to improve with immune therapies. Nakane and colleagues report that some patients with AAG improve with immunotherapies such as intravenous immune globulin (IVIg) therapy, corticosteroids, or plasma exchange. In a study including nine patients, Bouxin and colleagues suggested that rituximab (alone or in association with other treatments) could provide efficacy in treating AAG when plasma exchange and/or IVIg were not effective enough. Although rituximab has not been evaluated on a large scale in randomized trials due to the rarity of AAG, the use if rituximab in this clinical setting is supported by current medical literature regarding the auto-immune nature AAG and its response to immunologic regimens, along with case reports showing the efficacy of rituximab in the setting of concurrent plasma exchange. Therefore, rituximab is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested rituximab 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 medication 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 reviewer 1 is board certified in neurology with sub-specialty certification in vascular neurology and is actively practicing. Physician reviewers 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a pneumatic compressor with calibrated pressure and pressure pneumatic appliance for treatment of her left knee status post total knee replacement.  Three physician reviewers found that the pneumatic compressor with calibrated pressure and pressure pneumatic appliance was not likely to be more effective for this patient than other available treatment options. There is a lack of medical literature supporting pneumatic cooling devices after total knee surgery. There is a lack of defined benefit with treatment of pneumatic compressor with calibrated pressure and pressure pneumatic appliance over the use of conventional ice packs to reduce swelling. In this clinical setting, the standard of care is the use of conventional ice packs. The medical records and medical literature do not support the use of pneumatic compression cold therapy status post total knee surgery. All told, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result:  Three reviewers determined that the device at issue was 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 orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for GeneDx Autism/ID Xpanded Panel.Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. In this patients case, several prior genetic studies have been conducted, all of which failed to reveal a unifying molecular diagnosis to guide both treatment and surveillance strategies. The records indicate a logical and stepwise genetic evaluation has occurred. Neurodevelopmental disorders are often complex clinical scenarios from a genetic perspective. In a recent studies, 100 families with 119 children affected by neurodevelopmental disorders received diagnostic whole-genome sequencing and/or whole-exome sequencing, of which, forty-five percent received molecular diagnoses. Studies show, 78 patients with various neurodevelopmental disabilities and unrevealing work-up were selected to undergo multigene sequencing, with results yielding a presumptive diagnostic rate of 41%. Both studies demonstrated multigene sequencing to be a powerful diagnostic tool with results that directly impact patient care. Thus, GeneDx Autism/ID Xpanded Panel is likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in clinical genetics and genomics 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.