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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ketamine infusions for three to four days every three months, plexus neurolysis and sympathetic block with ultrasound guidance, and plexus neurolysis and sympathetic blocks with ultrasound guidance every three to six months. The American Society of Regional Anesthesia and Pain Medicine state that, evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Researchers found that there is a lack of evidence in the peer-reviewed medical literature to support ketamine infusions for the treatment of complex regional pain syndrome (CRPS). In this case, the patient has undergone multiple ketamine infusions with marginal benefit for management of her CRPS. The records document fewer than the three- and six-week cutoff offered by the most recent expert consensus panel on the treatment. The patient reported six days of relief with the inpatient infusions and two weeks with the outpatient infusions. The medical literature and specific results in this patients clinical scenario do not support the medical necessity of additional ketamine infusions. Thus, ketamine infusions for three to four days every three months are not medically necessary for treatment of this patient. In addition, the requested plexus neurolysis and sympathetic block with ultrasound guidance and plexus neurolysis and sympathetic blocks with ultrasound guidance every three to six months are not medically necessary for treatment of this patient. The evidence for this treatment modality is limited and there is a paucity of data in the literature to support brachial plexus neurolysis for CRPS. Moreover, this patient has a spinal cord stimulator implant in place with reported benefit. All told, ketamine infusions for three to four days every three months, plexus neurolysis and sympathetic block with ultrasound guidance, and plexus neurolysis and sympathetic blocks with ultrasound guidance every three to six months are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 reimbursement for the gene test (Afirma Thyroid Gene Expression Classifier) for evaluation of the enrollees thyroid nodules. Findings:  The physician reviewers found that The Bethesda System recommends a diagnostic hemithyroidectomy for this type of nodule. The recent American Thyroid Association guidelines state that for nodules with atypical of undetermined significance cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If the genetic test is suspicious, the risk of malignancy increases to greater than 40% and the risk of malignancy decreases to less than 6% with benign findings. In this case, the result of the Afirma Gene Expression Classifier was suspicious for malignancy. This increases the patients risk of malignancy to 40%. This information was important to determine the decision whether to perform thyroidectomy, and if so, the extent of surgery. For these reasons, the gene test (Afirma Thyroid Gene Expression Classifier) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and actively practicing. The reviewer 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

This patient is a three-year-old male with a history of speech and language delays.  His hearing has been tested and was determined to be normal.  The patient has been evaluated by two speech therapists and found to have mild receptive and moderate expressive language delays. There are no other developmental delays documented in the record provided for review. The patient has a history of behavioral issues which are believed to be related to his speech difficulties. His speech therapist noted good eye contact and cooperation during the evaluation.  The therapist suggested that the patients multiple ear infections are the cause of the speech delays, but there is no documentation of treatment for ear infections in the records from July 2005 through June 2006. The patients parent has requested authorization for speech therapy.  The Health Plan denied the request based upon a determination that speech therapy is not medically necessary.In reviewing the physician medical records for this patient there is no evidence of recurrent ear infections or intermittent hearing loss. The hearing evaluation included in the record shows the patients hearing is within normal limits. As such, I see no medical indication for speech therapy. The delays in this case appear to be developmental in nature and the parent may wish to pursue ancillary speech therapy services through the school system. Based upon the evidence provided for review, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested reimbursement for inpatient mental health services provided on 5/22/15. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient had several factors that were very concerning for relapse if she would have been discharged prematurely. Based on the documentation provided, the inpatient mental health services were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma Gene Expression Classifier (gene test). Findings:  The physician reviewers found that there is sufficient support for the Afirma Gene Expression Classifier (gene test) in this clinical setting. This patients biopsy revealed for atypia of undetermined significance. The Afirma testing was suspicious, and a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: All three physician reviewers 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: Overturned

The parent of a 20-month-old male enrollee has requested  for occupational therapy, physical therapy and speech therapy services for treatment of the enrollees developmental delay and speech disorder. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers (Shevell, et al). The main goal of treatment is to enhance the level of functioning. This patient has delays in fine motor, gross motor and adaptive skills of greater than 50% with cognitive delays of 40%.  Appropriate therapies including occupational and physical therapy are medically necessary in this setting and promote adaptive skill development and independence (Wolraich, et al). Therefore, the requested occupational and physical therapy services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested a cooling device and pump for local anesthetic infusion for a rotator cuff tear.  Findings:  The physician reviewer found that there is inadequate literature to support the use of a cooling device following rotator cuff surgery. There is no available data demonstrating that cryotherapy is more effective than the application of ice packs. No long-term data exists showing that cooling devices result in improved outcomes in this clinical setting. Furthermore, the use of an analgesic pump was not medically necessary based on the information provided. Standard pain management modalities would have been sufficient in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female has requested coverage for inpatient psychiatric hospital services from a specific date and forward for treatment of the enrollees major depressive disorder, severe, without psychosis, and bulimia nervosa.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  As of one week prior to admission, the patients vital signs no longer showed orthostatic changes, and her potassium level had returned to normal.  Per the submitted documentation dated on the date in question, the patient was consistently cooperative with the treatment program.  She ate 100% of her meals, and the documentation does not indicate binging or purging.  As of the date in question, the patient had no further medical problems which required close monitoring in an inpatient setting.  She did not express any suicidal thoughts during this time, and she did not engage in self-injurious behavior.  All told, inpatient psychiatric hospital services provided on the date in question and forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested real-time remote heart monitoring for evaluation of his lightheadedness and dizziness. Findings:  Three physician reviewers found that new technologies employing real-time remote heart monitoring have been developed and permit recording of cardiac arrhythmias without the need for patient activation.  These devices appear most appropriate for patient in whom there is a high likelihood of syncope or presyncope.  An additional important piece of clinical information is the frequency of the patients symptoms.  Frequent and recurrent symptoms are more apt to be diagnosed with Holter or loop monitors, while infrequent symptoms may not be amenable to diagnosis with these types of devices.  In this patients case, he was complaining of lightheadedness and dizziness in the setting of documented significant hypertension.  It was specifically noted that the patient had not experienced syncope or presyncope. In this clinical scenario, standard repeat Holter monitoring or loop monitoring technology would have been appropriate standard of care. Therefore, real-time remote heart monitoring was not likely to be of greater benefit than other available tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for migraine headaches, there is ample literature supporting its use when more traditional therapies fail.  In this particular case, the patient failed multiple standard first-line therapies for migraine. The evidence further establishes that Botox has in fact been effective for this patient in the past. Given the evidence-based data supporting the benefit of Botox for the treatment of migraines as well as the patients failure of standard preventive agents, Botox is likely to result in a superior clinical outcome in this case and should be authorized.
Appeal type: Urgent Care
Decision: Upheld

A 58-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient reported a cough for three weeks in duration. The cough was bothersome and prevented her from sleeping at times, but the medical record documents that the patient denied vomiting, chest pain, or shortness of breath. There is no evidence that the patient experienced a sudden worsening of her symptoms.She was in no distress and had normal lung sounds. A nebulizer was administered for symptomatic relief only.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 2 patients should be treated with daily Sovaldi and weight-based ribavirin 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 2 regardless of fibrosis stage.  All told, Sovaldi and ribavirin for 12 weeks are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who presented with right breast nodule.  Findings: Two physician reviewers found that the patient was diagnosed with a right breast nodule.  It is unclear whether this was found on a mammogram or whether this was a palpable nodule.  The patient had a right sided mammogram consisting of both two dimensional images as well as tomosynthesis.  A prior sonogram had identified a 6 mm lobulated nodule in the right breast.  The mammogram images were compared to the prior study as well as additional older mammograms.  The study, no masses, areas of suspicious calcifications, or areas of architectural distortion were identified.  The patients right breast was described as being heterogeneously dense. Following that negative study, it was recommended that she return for a six month follow-up sonogram. The patient requested reimbursement for breast tomosynthesis. The Health Plan has denied reimbursement of the service at issue noting that 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 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 apparently been found to have a right breast nodule.  It is unclear if this was a mammographic/sonographic finding or whether this was a clinically palpable lump.  A prior sonogram did demonstrate a small lobulated nodule.  Regardless, once a nodule has been found, it is imperative to fully evaluate the suspected abnormality.  In addition, the patients breast tissue was described as 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.  Therefore, the digital breast tomosynthesis rendered was likely to have been more effective than the available standard methods for evaluating this patient.Final Result: Two 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX Melanoma Gene Expression Assay for evaluation of her cutaneous melanoma.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the testing at issue. The use of Decision DX testing is not recommended outside of clinical trials according to the National Comprehensive Cancer Network guidelines. In addition, the testing at issue is not the standard of care in melanoma treatment or work-up. Final Result: The reviewer determined that the testing at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology 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  breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed  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. 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.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three 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. All three reviewers are experts erts 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 21-year-old male enrollee requested an ankle-foot orthotic (L1945) for medical treatment of his cerebral palsy. Findings:  The physician reviewer found that this patients records do not include a thorough evaluation by a specialist to support the requested AFO as medically necessary. A custom or prefabricated AFO may be appropriate for this patient with cerebral palsy. However, the patient needs a more thorough evaluation for this brace, preferably with a physiatrist with expertise in cerebral palsy or other neuromuscular conditions who are familiar with AFO devices. All told, the documentation does not support the medical necessity of the requested AFO device for treatment of this patients cerebral palsy.