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

The parent of a three-year-old male enrollee has requested occupational therapy for the enrollees autism. Findings: The physician reviewer found that the prevalence of impairments in fine and gross motor skills in children with autism appears to be relatively high based on the studies that have been published in the literature. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. They help set specific goals for the autistic patient. These goals often involve social interaction, behavior, and classroom performance. Studies have shown that OT benefits such patients by preventing a deterioration or reversal of function and increasing ability to participate in activities of daily living. Case-Smith evaluated six categories for the need of occupational therapy and showed that in all six areas, occupational therapy significantly helped the patient. According to the Guidelines for Autism by the American Academy of Neurology and Child Neurology Society developed in 2000, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. An occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. Thus, occupational therapy in this patient population is standard of care in the community. This patient has documented deficits in sensory processing, gross and fine motor skills, and self care skills secondary to a diagnosis of autism. Thus, the requested occupational therapy is medically appropriate and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable monitor by Lifewatch services. Albers and colleagues note that the diagnosis of cryptogenic stroke is a diagnosis of exclusion and may include extensive testing and that recent data from devices capable of continuous arrhythmia monitoring suggest that even brief episodes of atrial fibrillation (AF) may increase the risk of stroke. The authors further note that monitoring systems detect brief, rare episodes of AF in patients with stroke may include external, ambulatory, patch, and real-time continuous attended cardiac systems. Gladstone and colleagues note that early detection and treatment of AF, a preventable cause of recurrent stroke, are critical. In this case, the patient is age 40. Radiology notes reported findings consistent with left middle cerebral artery (MCA) stroke consistent with nonocclusive thrombus. The records showed that an extensive workup for structural heart disease, cerebrovascular disease, and a hypercoagulable state did not reveal an etiology. For this patient, a finding of occult AF would have marked clinical significance resulting in the need for long-term anticoagulation in the setting of a prior embolic stroke, and extended ambulatory monitoring was used to assess for occult AF. Given that asymptomatic paroxysmal AF remains a significant concern in patients with cryptogenic stroke, the use of the device at issue was appropriate to provide prolonged cardiac monitoring to elucidate AF and the cause of the embolic event. Therefore, the wearable monitor by Lifewatch services was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the wearable monitor by Lifewatch services at issue was likely to have been 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 likely to have been 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 and 2 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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

The patient is a seven-year-old female who has been receiving speech therapy since the age of two for speech delay. The results of an initial evaluation document both a receptive and expressive deficit with resolution of the deficits to within normal limits on follow-up testing. Because both receptive and expressive language was found to be within normal limits, an individual education plan was not established through the school system. The patients hearing test appears to be normal. A request has been made for reimbursement for speech therapy services from 1/6/03 through 5/27/03. The Health Plan has denied coverage for the therapy at issue on the basis that speech therapy was not medically necessary for treatment of the patients condition after December 2002.Upon review of the literature regarding auditory processing disorders there is no support for active therapy in a patient with expressive and receptive language skills that are within age appropriate norm. The patients test results reflect some deficiencies in auditory comprehension; however, there is no evidence speech therapy can improve these deficiencies within a reasonable amount of time. To date, no adequate scientific studies have documented the efficacy of speech therapy on these deficits. Therefore, I have determined that the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees femur fracture. At issue in this case is whether the requested physical therapy is medically necessary for treatment of the enrollees medical condition.Based on the clinical information provided, the patient improved significantly with skilled intervention from her occupational and physical therapist. The therapists both documented that the claimant was safe and had met goals for discharge. She was discharged from ongoing care by the occupational therapist. In addition, she was independent with transfers and was able to ambulate household distances according to the physical therapist. Given these clinical findings, the medical records do not support that the patient requires ongoing intervention by the physical therapist. The patient is safe to transition to a home program for ongoing exercise. There is moderate evidence that physical therapy can help in the initial phase of rehabilitation, but in this case, given her clinical improvement, ongoing physical therapy would not be warranted at this time. Therefore, the requested physical therapy is not medically necessary.Final Result: The reviewer determined that the requested treatment 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anti-reflux surgery utilizing LINX Reflux Management System for treatment of her medical condition. Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies at four years are encouraging.  However, to date, the studies investigating LINX have been open label, observational studies.  There is a lack of head to head randomized trials with standard surgical treatment.  All told, the LINX Reflux Management System is not likely to be more effective than other treatment options. Final Result: Three reviewers determined that the requested services 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Belbuca for treatment of her medical condition.  Findings: The physician reviewer found that the request for Belbuca was not and is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, not all non-opioid treatment options have been utilized or optimized. In addition, there is no mention the patient has trialed behavior therapy given the support for its use (Lee, et al).  For these reasons, the requested for Belbuca was not and is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for his Oncotype Dx Prostate Cancer Assay.  Findings:  Three physician reviewers found that while the Oncotype Dx Prostate Cancer Assay has the propensity to determine the risk of recurrence and sometimes change therapeutic intervention based on risk, there is currently a lack of well designed, controlled clinical trials to demonstrate an improvement in health outcomes based on its use.  The National Comprehensive Cancer Network guidelines lists Oncotype Dx for patients post biopsy for patients with very low risk and low risk prostate cancer who did not receive therapy and are candidates for surveillance or active therapy with a life expectancy of 10 years. This patients prostate cancer was not newly diagnosed and the initial Oncotype was done in 2013. This patients progression of the Gleason score over a period of three years from 6 to 7 was enough to demonstrate progression. Thus, the Oncotype Dx Prostate Cancer Assay provided did not add any additional information not provided by the clinical situation and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested Xiaflex for medical treatment of his Peyronies disease.   Findings:  The physician reviewer found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. In addition,  Xiaflex is the only FDA approved drug for Peyronies disease. This patient has failed conservative therapy and has or exceeds the other requirements for treatment with Xiaflex.  All told, the requested Xiaflex is supported as medically necessary for treatment of this patients Peyronies disease. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 32-year-old female enrollee has requested for emergency services for treatment of her upper respiratory symptoms.  Findings:  The physician reviewer found that this patients Health Plan provides emergency services when medically necessary. An emergency medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention would result in placing the members health in serious jeopardy. Medical records in this case document that the patients symptoms had gradually commenced over five days. Her physical exam was significant only for nasal edema. She was not having any pain and was not in any respiratory distress. Since this patients symptoms were not acute in onset, and she was not experiencing any chest pains or severe symptoms, they do not meet criteria for an emergency.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis often allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers especially in patients with heterogeneously or extremely dense tissue.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with the two-dimensional technique alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bone density test (CPT code 77081). Findings:  Three physician reviewers found that the medical evidence does not support the services at issue in this patients case. There is a lack of clinical documentation to show why this patient needed peripheral bone density testing instead of a standard bone density test, where the spine and hips are imaged. Peripheral bone density devices are portable machines that use the same technology as dual-energy x-ray absorptiometry (DEXA) to measure bone mineral density at peripheral sites, such as the forearm. Evaluation of fracture risk prediction with these machines is confounded by technical differences, variation in the definitions of the bone regions of interest measured, and lack of standardized reference databases for calculating T-scores. Peripheral bone density cannot be used for diagnostic classification, other than with measurement at the distal one-third radius site to evaluate for conditions like primary hyperparathyroidism. In sum, bone density test (CPT code 77081) was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The patient has requested authorization and coverage for radiofrequency ablation of the right and left perforator veins with possible ultrasound guided sclerosant. Currently, this patient does not have ulceration and there is untreated significant reflux in the bilateral GSV. Due to the elevated risks of deep vein thrombosis (DVT) and procedural failure, treatment of perforator vein reflux is reserved for patients with recalcitrant ulcers. This patients symptoms are likely to improve with further GSV treatment. Based on the available documentation, the requested radiofrequency ablation of the right and left perforator veins with possible ultrasound guided sclerosant is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with subspecialty certification in vascular 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 61-year-old male enrollee has requested proton beam radiation therapy for the treatment of his prostate cancer.  Findings:  The physician reviewer found that the patient has a very localized tumor with Partins tables suggesting a 99% likelihood of containment within the volume of the prostate. The side effects of all forms of radiation therapy are relatively low. This is especially true with IMRT, which is a form of treatment available to the patient. He appears to have a good understanding of the various modalities and is aware and assured that the local control and overall cure rate are the same for both proton beam and IMRT. As the side effects are minimal and manageable for both forms of treatment, I see no medical indication for proton beam radiation therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested for residential substance abuse treatment for treatment of her behavioral health problems.   Findings:  The physician reviewer found that per the American Society of Addiction Medicine (ASAM) Criteria, the level of care necessary for a patient with substance abuse is determined by a number of factors including likelihood of acute withdrawal symptoms; attitudes toward treatment/readiness to change; other biomedical conditions; other emotional, psychological and cognitive condition; relapse/continue use/continue problem potential; and recovery environment (social supports at home). In this case, as of the last authorized date of service, withdrawal was no longer a concern. While there was some depression involved, it was situational in nature and not a longstanding problem, as the patient had been sober for 10 years prior. Furthermore, the patients bipolar disorder was not acutely active during her admission. While there is some relapse potential, particularly with the methamphetamine use, the patient was very motivated towards treatment and the home recovery environment was reasonable.
Appeal type: Experimental/Investigational
Decision: Overturned

A 29-year-old male enrollee has requested for a PET scan for evaluation of his Ewings sarcoma. Findings:  Three physician reviewers found that according to the National Cancer Institute, PET scans in patients with metastatic Ewings sarcoma have a relevant impact on therapy planning. The conventional studies (bone scan and CT studies) did not show the patients recent recurrent pelvic tumor. To properly re-stage this patient, a PET scan is medically appropriate and indicated, as conventional imaging has not been able to properly ascertain this patients disease state.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested brachy radiation for treatment of her condition status post excision of pterygium with conjunctival autograft.  Findings:  The physician reviewer found that the use of additional prophylactic therapy for a primary pterygium, such as Beta irradiation, is not the standard of care due to associated risks including scleral melting with possible secondary infection. Further, the scientific literature lends support to the use of supplementary therapies such as Beta irradiation only when a patient later requires removal of a recurrent pterygium. The standard of care remains primary pterygium surgery with a conjunctival autograft without prophylactic Beta irradiation therapy.