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

The parent of a six-year-old male enrollee has requested speech and language therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient has speech delay and fine motor skills delay requiring speech therapy and occupational therapy. Occupational therapy addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development in children. In addition, occupational therapy combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development.  The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorder. In this patients case, the assessment by the speech therapist did not provide prognosis for outcome. However, the provider noted profound delays.  Evaluation and management of individuals with autism spectrum disorder requires a comprehensive, multidisciplinary approach.  All told, speech and language therapy and occupational therapy are medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam therapy. Findings:  The physician reviewer found that There is no data to suggest that proton therapy would be beneficial in this case or that it would be associated with less side effects than standard treatment with photons. The standard treatment in this case would be with chemotherapy, followed by surgery, followed by radiation with photons. Furthermore, consensus group guidelines do not support the use of proton therapy in this setting (NCCN Clinical Practice Guidelines). In the vast majority of cases, intensity modulated radiation or 3D conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. There is also no level I evidence to support the use of proton therapy for the treatment of breast cancer. Therefore, the requested proton beam therapy is not likely to be more beneficial than any other available standard treatment for the patients condition.Final Result: The reviewer determined that the requested services are not likely to be more beneficial than any other available standard treatment for the patients condition. Therefore, the Health Plans denial should be upheld.Findings: Three out of three physician reviewers found that the requested proton beam therapy is not likely to be more beneficial than any other available standard treatment for the patients condition.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested venous angioplasty for treatment of her history of right axillo-subclavian vein thrombosis. Findings:  Two physician reviewers found that the requested services are likely to be of greater benefit than other treatment options.  There is sufficient support for the requested services in this clinical setting.  The requested venous angioplasty is likely to result in better long-term outcome.  Based upon the medical records, venous angioplasty is indicated to decrease the long-term sequelae of venous outflow obstruction.  This patient is status post first rib resection, and the requested venous angioplasty is likely to be superior over other alternatives in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an in-home light therapy for treatment of her dyshidrotic eczema. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested in-home device. Generally, (UVB) light phototherapy is administered in an outpatient clinic two or three times per week.  The patient is seeking coverage for an in-home light unit because it is difficult for her to attend office-based phototherapy given her work schedule. There is no documentation of any medically-based barriers to in-office treatment. Nor is there evidence that the patient is physically limited in her capacity to seek office-based treatment. All told, the requested in-home unit is for purposes of convenience and is not clinically indicated. In sum, the in-home light therapy unit is not medically necessary for the treatment of this patients medical condition.  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 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for botox injections.Findings: Two out of three physician reviewers found that the requested botox injections are not likely to be more beneficial than any other available standard treatments for the patients medical condition.There is not sufficient support for the requested services in this clinical setting. Botulinum toxin injection (botox) is not approved by the U.S. Food & Drug Administration (FDA) for the treatment of gastroparesis. At this time, there is not sufficient scientific evidence to support the safety and efficacy of botox injection for the treatment of gastroparesis in children. Clinical practice guidelines adopted by the American College of Gastroenterology (ACG) state that botulinum toxin injection into the pylorus is not recommended as a treatment for gastroparesis. The safety and long-term efficacy of pyloric botox injections in treating gastroparesis in children is not established or proven. There is no well-structured scientific evidence (i.e. randomized prospective clinical trials) supporting the safety and long-term efficacy of this treatment in children with gastroparesis. Accordingly, the requested botox injections are not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in pediatrics, with subspecialty certification in pediatric gastroenterology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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: A 66-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the prostate with or without contrast. This patients rising PSA and the prior MRI scan which was suspicious for cancer in the left prostatic base warrant consideration of biopsy. Thus, MRI of the prostate is supported as medically necessary if there is also the ability to perform a targeted biopsy should a lesion be found at the time of the examination. Such a procedure can be done with a fused ultrasound guided biopsy correlating with the MRI scan. This approach would allow for the prostate to be examined by MRI and ultrasound done at the same time to allow for a specific target to be biopsied as suggested by the provider in 2017. If no definitive lesion is seen on the MRI, the provider may opt for surveillance rather than tissue sampling. However, if a suspicious lesion is visualized, the imaging can guide the provider to the exact location for biopsy. To perform another MRI without the ability to target a specific area to biopsy is unreasonable based upon the clinical factors as well as the suspicious findings leading to a PIRADS 5/5 diagnosis in 2017. Thus, the requested MRI of the prostate with or without contrast is medically necessary so long as a targeted biopsy is performed at the time of imaging, should a lesion be found at the time of the examination. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 reimbursement for gene testing for evaluation of the enrollees eye cancer. Findings:  Two physician reviewers found that the patient was diagnosed as having choroidal melanoma based on a fine needle aspirate. The specimen was submitted to pathology and for genetic testing to determine the risk of metastasis. The patient requested reimbursement for gene testing but the Health Plan has denied the patients request for reimbursement. Per the Health Plan, the services at issue were investigational for the evaluation of this of this patient. There is sufficient scientific evidence that genetic testing of the uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis. Gene tests provide reliable information for providers as they determine a treatment course for their patients. Gene tests have been used to identify disease progression for several years. Moreover, the medical literature shows gene test has become part of the standard of care in patients who are diagnosed with uveal melanoma. The studies have shown that providers who treat patients diagnosed with uveal melanoma routinely use and offer gene test to their patients. These genetic tests assist providers in their monitoring and screening of these patients for metastasis. Furthermore, there may be a small window of time, in cases of uveal melanoma, to retrieve a sample tissue because the primary tumor may no longer be available to biopsy should the patient elect to undergo radiation plaque therapy. As such, gene testing provides critical prognostic information that would not be available otherwise. Therefore, the genetic testing performed was likely to be more efficacious to other treatment options for evaluation of this patients medical condition. Final Result: The reviewers have 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 physician reviewers are board certified in ophthalmology 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 an 11-year-old female enrollee has requested authorization and coverage for weekly individual psychotherapy services.  Findings:  The physician reviewer found that based on review of the available records, the medical documentation does not support the medical necessity for weekly psychotherapy. A letter from the patients provider describes recommendation for weekly psychotherapy, noting the ongoing challenges related to her brothers psychiatric illness, as well as diagnoses of adjustment disorder with mixed anxiety and depression. Progress notes from same provider indicate the therapist mentioned going from weekly to every other week. Progress notes from a later date notes the patient enjoyed a social event with her friends. The providers notes approximately a month later describe the patient as bouncy; the note references the patient helping with birthday parties over the summer. The patients child psychiatrists notes dated three months later indicates good compliance with medications, no side effects, and no positive findings under risk assessment. Several notes from treating psychiatrist indicate the patient has good social skills, has friends, and is involved in age appropriate activities. The patients GAF scores provided by her psychiatrist have ranged from 60-71. Overall, the medical documentation does not provide a contraindication for decreasing therapy sessions to every other week as discussed by the therapist. As indicated by the American Psychiatric Association (APA), treatment reduction should be gradual. Similarly, the American Association of Child and Adolescent Psychiatry (AACAP) practice parameters on systems of care note the value of utilizing natural community supports and resources as part of a comprehensive treatment plan. The current peer reviewed literature also indicates cognitive behavioral therapy (CBT) is one of the most effective evidence-based treatments for childhood anxiety. Consistent with these findings, the patient should receive individual sessions at the frequency of twice per month with an updated treatment plan, assessment, and documentation of response to treatment. Therefore, a portion of the requested therapy has been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin. Nutropin AQ NuSpin is medically necessary for treatment of this patients medical condition.The submitted documentation supports the requested medication in this clinical setting. The age of two is the age at which GH therapy is recommended by the U.S. Food and Drug Administration for treatment of small, for gestational age, with failure to catch up.  However, GH therapy is medically necessary for this patient even though she does not meet the recommended age for GH therapy. The records demonstrate that this patient has extreme stunting of growth in association with Silver-Russell syndrome and would not likely catch up to the normal curve by two years old. Accordingly, the initiation of GH therapy at this point in time is supported by the clinical evidence. All other causes of poor growth, such as malabsorption and allergy, have been ruled out by other specialists. The benefits of treating patients who are diagnosed with Silver-Russell syndrome with GH have been shown to extend beyond improvement of stature growth. GH therapy in this patient population may also benefit with improved body composition, motor development, appetite, as well as a reduced risk of hypoglycemia. For the reasons noted above, Nutropin AQ NuSpin is medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 49-year-old male enrollee has requested epidural injections for treatment of his low back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The peer-reviewed medical literature does not support a series of epidural steroid injection in treating the patients medical condition. Novak and Nemeth performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections, to help determine what sort of responses should occur to repeat an injection and to outline specific research needs in these areas. The authors found that there was limited evidence to suggest guidelines for frequency and timing of epidural steroid injections or to define what constitutes the appropriate partial response to trigger a repeat injection. In addition, Abdi and colleagues performed a systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and criteria of Cochrane Musculoskeletal Review group for randomized trials. The authors reported that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given the peer-reviewed medical literature cited above, and that the patient did not experience long-term relief (greater than 6 weeks), or demonstrate reduced use of medications and adjunctive therapy (physical therapy, heat and ice) with the first epidural steroid injection, repeat epidural steroids are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested somatropin (Genotropin) growth hormone for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on the available medical records, this patient has short stature but normal growth velocity, normal growth factors, and a normal response to provocative GH testing. There is no known morphological abnormality of the pituitary gland or midline structures. Given his age, it is too early to make a prediction of final adult height. It is difficult to distinguish whether the patients short stature and delayed bone age are due to constitutional delay or occult systemic disease. According to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient satisfies only two of these criteria, and no information is provided to document that all other systemic and nutritional causes of short stature have been ruled out. All told, there is inadequate evidence to support the medical necessity of Genotropin GH treatment for treatment of this patients short stature.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Avastin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees stage IV colon cancer.The request for Avastin is medically necessary for treatment of the patients medical condition. In this case, the patient presents with stage IV colon cancer and has completed 12 cycles of chemotherapy with FOLFIRI and then capecitabine both in conjunction with Avastin. Avastin was then continued as maintenance therapy. The use of single agent Avastin after use in combination with chemotherapy is considered a standard of care for patients with stage IV colon cancer. In addition, it is supported by the National Comprehensive Cancer Network (NCCN) guidelines and the peer-reviewed literature. For the reasons provided, treatment with Avastin has been established as medically necessary for treatment of the patients medical condition.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 medical oncology and hematology 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.