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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for the enrollees breast cancer screening. Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  She underwent a routine screening mammogram consisting of two dimensional images.  On that mammogram, there was a questionable abnormality observed on only the cranio-caudal view, and further imaging was recommended.  She returned for spot compression and magnification views.  In addition, a breast tomosynthesis as well as a targeted sonogram were performed. The images were compared to prior mammograms and the more recent mammogram.  No significant abnormalities were seen. There were no masses, areas of architectural distortion, or abnormal calcifications.  The prior abnormality was felt to represent summation artifact. During their studies, the breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis portion of the examination performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In this patient, breast tomosynthesis was utilized as a problem solving tool.  Once a questionable abnormality was noted, further imaging was appropriately performed. Breast tomosynthesis was warranted on both that basis to evaluate the suspected abnormality as well as to evaluate the dense nature of her breasts.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For these reasons, the digital breast tomosynthesis performed was superior to the available standard modality available for evaluation of this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition, the area of architectural distortion, felt to be likely post-surgical, can also be best evaluated with tomosynthesis. Therefore, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: All three 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: Experimental/Investigational
Decision: Overturned

The parent of a four-year, eleven-month old female has requested PROMPT therapy, which includes speech therapy at a frequency of five hours per week and social skills training at a frequency of six hours per week for treatment of her childhood apraxia of speech.  Findings:  Two physician reviewers found that the patient has been diagnosed with severe apraxia of speech, as well as a mixed expressive/receptive language disorder and impaired communication skills. As a toddler, she was treated at an early childhood partial hospitalization program (PHP), which utilized a comprehensive and multidisciplinary program, including prompts for restructuring oral muscular phonetic targets (PROMPT) techniques. She was discharged from the PHP three years ago with a diagnosis of childhood apraxia of speech. Continued intervention utilizing the PROMPT method was recommended. The patient continued with speech therapy, with minimal improvement. She was then transferred to a private therapist with experience in childhood apraxia of speech, and who utilized the PROMPT therapy method. The patients parents report that the patient has made significant progress since beginning the PROMPT therapy method. Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and language-delayed children have also shown increased behavioral difficulties and impaired psychosocial adjustment (Nelson, et al.). Overall, children with speech delays who are treated with speech therapy have demonstrated positive gains in speech and language development in the areas of expressive phonological skills and expressive vocabulary skills (Law, et al.). Verbal apraxia or apraxia of speech is an impairment in planning and coordinating movements for speech production (Kleigman, et al.) which affects the ability to voluntarily initiate goal-directed speech or imitate speech. This is a deficit in motor programming and sensorimotor processing at the central level and is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, children with apraxia of speech communication at all levels may be ultimately impaired (Lewis, et al.). The PROMPT method of therapy has been used for a number of years to successfully treat children diagnosed with childhood apraxia of speech (Grigos, et al.). In this case, the patient has been treated with the PROMPT therapy method with gains in social skills. The patient continues to present with expressive and receptive language delays. Given the intensity of service offered by the PROMPT approach, it is likely to be more beneficial than standard therapies for treatment of the patients severe apraxia of speech and mixed expressive/receptive language delay.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care.  The enrollee has a history of anxiety and substance abuse with alcohol, marijuana, cocaine, and methamphetamines. Findings:  The physician reviewer found that criteria indicate residential treatment is a medically necessary treatment when there is a need for opioid treatment services (Level 5), and/or withdrawal management services (Level 6).  The composite score required for level 5 is 23  27 and the required composite score for level 6 would be 28 or more.Review of the record indicates a composite score of 23, which, supports residential level of care.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the platelet-rich plasma (PRP) injection for treatment of the enrollees neuroma of the left foot. Findings:  The 3 physician reviewers found that There is a paucity of information available in the literature concerning the effectiveness of PRP injection for treatment of neuroma pain. PRP provides a promising alternative to surgery or other invasive treatment modalities.  However, authors conclude that there are too few controlled trials and sample sizes are too small. Therefore, authors conclude that more large controlled studies are needed. In sum, there are a lack of controlled trials to conclude that PRP is better than any other standard treatment for musculoskeletal conditions. Therefore, the PRP injection provided was 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 service 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: Physician reviewer number one is board certified in podiatry 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 podiatry 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 podiatry 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 51-year-old male who has been diagnosed with moderate obstructive sleep apnea (study performed in July 2004). The patient indicates he has undergone several surgeries in attempts to correct this problem. The most recent surgery was that of revision septoplasty and inferior turbinate reduction. This was performed in February 2005. The patient continues to be symptomatic in terms of obstructive sleep apnea. He has requested authorization for a follow-up sleep study. The patient wishes to have his repeat study performed at an out-of-network facility. The Health Plan has denied this request indicating appropriate services are available from an in-network provider.The Health Plans denial should be upheld. There is no evidence the patient requires the services of an out-of-network provider. The Health Plan indicates appropriate sleep study services are available from an in-network provider. Based upon the evidence provided, there is no justification for a referral for out-of-network sleep study services. The patient should be referred to an in-network provider whose practices are within standard of care. Accordingly, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings: Three physician reviewers found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the digital breast tomosynthesis 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A forty-seven year-old female who has diffuse pain, muscle spasms and lower extremity weakness as well as left-sided paresthesias is requesting authorization for a power-operated vehicle.  Reviewers Findings:  The reviewing physician found that the records provided for review are not supportive of the need for a power-operated vehicle.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested the Afirma fine needle aspiration analysis for medical evaluation of her bilateral thyroid nodules.  Findings:  Three physician reviewers found that National Comprehensive Cancer Network (NCCN) guidelines for thyroid carcinoma indicate that for FLUS, where the clinical suspicion is low for malignancy, testing with genetic markers (Afirma) is indicated as a category 2b recommendation. In this case, the risk of malignancy cannot unequivocally said to be high. Therefore, the Afirma test performed was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injection for treatment of the enrollees medical condition. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patients clinical presentation suggests proctalgia fugax.  Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain/spasm that are self-limited.  The diagnosis of proctalgia fugax requires exclusion of other causes of rectal or anal pain.  Anorectal pain may be caused by hemorrhoids, anorectal abscesses, anal fissures, rectocele, rectal cancer, inflammatory bowel disease, chronic benign prostatitis, and coccydynia. These conditions appear to have been excluded by the evaluation. Topical therapy including nitroglycerin and diltiazem are first-line treatment. If this is ineffective, then biofeedback may be prescribed.  The medical evidence does not support Botox injection in this patients case.  All told, Botox injection is not likely to be superior over treatment options.Final Result: Two reviewers determined that the services at issue are 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 physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 31-year-old male enrollee requested authorization and coverage of monthly protime checks for  anticoagulation therapy.  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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a cochlear implant in the left ear. Cochlear implantation improves communication ability in patients with profound hearing impairment. The American Academy of Otolaryngology  Head and Neck Surgery (AAOHNS) considers unilateral and bilateral cochlear implantation as appropriate treatment for adults and children over nine months of age with moderate to profound hearing loss who have failed a trial with appropriately fit hearing aids. In this case, the patient has moderate hearing loss in the right ear and profound hearing loss in the left ear. She has benefited from hearing aid use in the right ear. An otologic examination was normal. Her otologic examination was normal, and magnetic resonance imaging (MRI) showed bilateral enlarged vestibular aqueducts, and cochlea that were otherwise normal. In this case, even though the patient has bilateral hearing loss, the patient has responded well to hearing aid therapy in the right ear and thus has not failed a trial of hearing aids in both ears. This would not meet AAOHNS guidance for cochlear implants. Likewise, a recent systematic review by researchers concluded that there remains no high-level evidence strongly supporting cochlear implants in asymmetric hearing loss. Accordingly, the requested device is not medically indicated. Therefore, a left ear cochlear implant is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 otolaryngology  head and neck 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 digital breast tomosynthesis for the evaluation of the enrollees risk of breast cancer. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram consisting of a combination of two dimensional and three dimensional tomosynthesis examination. The current images were compared to a prior mammogram, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis stating that digital tomosynthesis was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, she has breasts that have been described as being heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three physician reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three 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: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for an oral device to reduce upper airway collapsibility for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, the request for an oral device to reduce upper airway collapsibility is medically necessary for treatment of the patients medical condition. In cases of mild and moderate OSA, oral appliance (OA) therapy is as an appropriate first-line therapy. In this case the patient is noted to have mild OSA. According to the American Academy of Sleep Medicine (AASM) guidelines Although not as efficacious as CPAP, OAs are indicated for use in patients with mild to moderate OSA who prefer OAs to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail CPAP or behavioral measures such as weight loss or sleep position change. In addition, the joint practice guidelines from the AASM and the American Academy of Dental Sleep Medicine (AADSM) state We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. As such, an oral appliance is supported by current practice guidelines for this patient who prefers alternate therapy with an OA. In addition, the patient has no dental issues that would prevent the use of an oral appliance. The use of an oral appliance in this case would be considered to be clinically appropriate and medically necessary based on current practice guidelines. For the reasons provided, the requested device is medically necessary for treatment of the patients medical condition. 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 neurology with sub-specialty certification in sleep 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.