Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

A 24-year-old female enrollee has requested an emergency room visit for the treatment of her abdominal pain. Findings:  The physician reviewer found that the enrollee suffered from severe abdominal cramps as well as reported nausea, fever, chills and malaise. A prudent layperson would have sought immediate medical attention due to the severity of her pain as well as her associated symptoms. There are a variety of potentially life-threatening conditions that present with such symptoms including appendicitis, kidney stones, urinary tract infection, pyelonephritis, ovarian torsion, pelvic inflammatory disease and others. Although it is fortunate that this enrollees condition improved with anti-emetic treatment, these other potentially life-threatening disorders could not have been ruled out without emergency medical evaluation. If she had not sought care, and had appendicitis or one of the other disorders, her condition could have possibly become life threatening (such as perforation of an infected appendix).
Appeal type: Medical Necessity
Decision: Upheld

The patient is a five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary. Though the submitted records indicate the patient has had a positive response to Adderall XR it has not been established that Adderall XR is medically necessary for treatment of the patients ADHD. The records demonstrate the patient had significant positive response to immediate release Adderall. There is no documentation of significant rebound on the immediate release version of Adderall. Furthermore, Adderall XR has not been approved for use in children under the age of six. Moreover, the submitted documentation does not demonstrate the patient has experienced complications that would warrant use of the long-acting version of Adderall. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year 10-month-old female enrollee has requested speech therapy evaluation and speech therapy services for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that this nearly three-year old patient is significantly delayed in the development of expressive language. She has made no change in her language over an eight-month span, as documented by her pediatrician. Specific expressive developmental delay is due to a developmental maturation delay in brain function secondary to a congenital brain dysfunction, which has eluded specific etiology. Prelock and colleagues state that, Speech language deficits are the most common of childhood disabilities.  The authors also emphasize that the consequences of untreated speech language problems are significant and lead to behavioral changes, mental health problems and academic failure.  Additionally, an article by Buschman and colleagues specifically deals with children of this patients age. This paper is a controlled study of two-year-old children with delayed developmental expressive language. For a three-month period, the treatment group received speech therapy along with a program of parental interventional instruction. The authors found that 75% of the children enrolled in the experimental group were brought to normal expressive speech while only 8% in the control group reported spontaneous improvement to normal speech. Nye and colleagues further describe the effectiveness of speech therapy in children with expressive speech developmental delay. Thus, the literature clearly supports the need for intervention in patients with congenital expressive speech delay, as well as the effectiveness of speech therapy in this patient population. It also confirms the theory that failure to treat such patients can have serious complications altering overall normal development. Speech evaluation and speech therapy services are medically necessary for treatment of this patients expressive developmental delay resulting from congenital brain dysfunction.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female has requested past and future coverage for intensity modulated radiation therapy for treatment of her invasive ductal carcinoma status post mastectomy and chemotherapy.  Findings:  Two physician reviewers found that the patient has a T2NO high grade carcinoma of the left breast. The pathology revealed weakly estrogen receptor positive (1+, 1-10%), progesterone receptor negative, and HER2/NEU- disease. The patient underwent 12 cycles of weekly paclitaxel/neratin on a clinical trial. There was significant progression of the primary and nodes including supraclavicular  and cervical adenopathy. The patient was then treated with AC chemotherapy with excellent clinical and radiographic response. Following chemotherapy she underwent a left breast total mastectomy which revealed persistent disease measuring 2.5 cm in size with negative margins and no evidence of angiolymphatic invasion. Her sentinel lymph node was negative. However, two non sentinel nodes revealed isolated tumor cells. She had immediate reconstruction with an expander. The records indicate the patient has been treated with intensity modulated radiation therapy (IMRT). This patient had progressive disease on neoadjuvant chemotherapy, following additional chemotherapy and surgery. For this reason, her provider recommended treatment of the reconstructed breast, internal mammary, supraclavicular and left low cervical lymph node chains with radiation to improve local control and survival. In the relevant medical literature, IMRT is noted for the advantage of beam shaping to spare the heart and left lung to a greater degree than a 3D conformal plan. Thus, although in early stage breast cancer there is no advantage in the use of IMRT over 3D conformal therapy based upon the trials conducted, in this patients case because of the need to cover the internal mammary chain, IMRT offers superior coverage of the target tissues and better sparing of the organs at risk.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested authorization and coverage for occupational therapy visits for treatment of the enrollees difficulty feeding.  Findings:  The physician reviewer found that feeding difficulties are common with an estimated prevalence of 25%-45% in normally developing children and up to 80% in developmentally delayed children. The need for timely and effective treatment is essential to prevent failure to thrive and related complications. Successful treatment requires interdisciplinary approach involving several providers. There is evidence in the literature to support the need for occupational therapy in the treatment of feeding difficulties.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee requested intravenous immune globulin (IVIG) therapy for medical treatment of her pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS).  Findings:  The physician reviewer found that presently, the clinical trial for IVIG for PANDAS is closed to enrollment, but ongoing evaluation of IVIG efficacy in children diagnosed with PANDAS, has a 3 year follow-up window.  Until these results are published and after the appropriate peer review, no conclusion, favorable or unfavorable can be made. Moreover, the association of streptococcal infection with basal ganglia disease, in particular, obsessive compulsive disorder and movement disorders such as Tourette syndrome, remains controversial. While neuroimmune abnormalities may or may not be present in children that carry a diagnosis of tic disorder, OCD and history of streptococcal infections, systematic studies that have addressed this find no supportive evidence for neuroimmunologic dysregulation secondary to streptococcal infection. All told, the medical necessity of the requested therapy has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight weeks. According to the most recent guidelines, all patients with chronic HCV should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment naive, genotype 1 patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection, regardless of fibrosis stage. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The husband of a deceased female enrollee has requested stereotactic surgery for the treatment of the enrollees metastatic breast cancer. Findings:  Two physician reviewers found that this patient had metastatic cancer of the breast with pulmonary metastases, and she had few treatment options available to her when her middle bronchus was completely occluded with breast cancer. Conventional radiation therapy was not possible due to her previous chest wall irradiation for her primary breast cancer. Stereotactic surgery could overcome the previous chest wall, which was irradiated anteriorly. In addition, it could minimize the radiation to her esophagus. Stereotactic surgery was her best choice and also the only choice.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Synvisc-One injections. The Health Plan has denied the requested services as investigational for treatment of the enrollees osteoarthritis of the knees.Findings:  The physician reviewers found that the requested injections are not likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Findings:  Two out of three physician reviewers found that the guidelines for treatment of osteoarthritis of the knee does not recommend hyaluronic acid (HA) for patients with symptomatic osteoarthritis, based on strong evidence. Fourteen HA studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet their minimum clinically important improvement thresholds. It was conceded that there might be some subgroup of responders who could be helped by HA, but that subgroup has not yet been identified. In this case, the clinical documentation does not include imaging reports demonstrating the presence of severe osteoarthritis. Further, the records do not report that the enrollee is having pain that interferes with functional activities or has failed treatment with intra-articular corticosteroid injections. Thus, the Synvisc-One injections are not likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. One physician reviewer found that viscosupplementation is recommended in enrollees with a history of lasting benefit from prior injections and in carefully selected cases where conservative modalities have failed and the remaining treatment options are limited. In this case, there is known benefit from a Synvisc-One injection of the right knee, and the options are limited, with the alternative being a total knee arthroplasty. As such, Synvisc-One injections are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy.Final Result: The reviewers determined that the requested injections are not likely to be more beneficial for evaluation of the enrollees 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 orthopedic surgery 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 Afirma Gene Expression Classifier testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the services at issue were likely to have been of greater benefit than other modalities for 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The patient is a 50-year-old male who underwent successful ACL reconstruction in September 2003. The patients knee is now stable and the information presented does not explain symptoms or issues of concern regarding the patients rehabilitation. The patient is seeking authorization for a custom ACL knee brace.The Health Plans denial should be upheld. There is no Class I literature/evidence to support the need for the requested knee brace for this patient. Furthermore, the patient underwent successful surgery almost nine months ago and his knee is now stable. The patient wishes to have the brace so that he may continue playing soccer. There is no evidence establishing that a custom brace is necessary for the patient to return to athletic activities.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 47-year-old woman with new onset of chronic daily headaches with migraine features. Her headaches are disabling, causing frequent ER visits and missed time from work. The patient has been under the care of a neurologist and pain management specialist. She obtains relief from triptans. She has failed multiple preventive medications including Depakote and Neurontin as well as Elavil. She has had moderate relief of pain with prior Botox use. A request has been made for additional Botox injections. The Health Plan has denied coverage for Botox therapy on the basis it is not medically necessary for treatment of the patients medical condition. The patient has intractable headache, which has features of migraine. Review of the records provided indicates the patient has responded to Botox in the past. In addition, this patient has failed multiple migraine preventive agents and has severe disability related to her migraines. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested for intensive outpatient mental health eating disorder treatment for treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient needed additional treatment, but this additional treatment could have safely and effectively been administered at a lesser level of care such as regular outpatient therapy.There is no evidence that would suggest that continued intensive outpatient treatment was medically necessary under these circumstances for the patient, as opposed to the offered alternative of outpatient treatment on a less intensive (but twice weekly) basis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services. Findings:  The physician reviewer found that he American Society for Gastrointestinal Endoscopy (ASGE) guidelines for sedation and anesthesia in gastrointestinal endoscopy concluded that, the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events (Early, et al.). The ASGE guidelines recommend anesthesia provider-administered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. A review study performed by Wernli and colleagues found that the use of deeper levels of anesthesia was associated with a 13% increase in complications including bowel perforations. In this case, the patient underwent a routine colonoscopy. The patient did not have any significant  lung, kidney, or liver disease. The patient has a previous history of supraventricular tachycardia (SVT) which was treated with ablation, at the time of his evaluation he was found to be asymptomatic in normal sinus rhythm.  There was no documentation of a  history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented. The patient was given an American Society of Anesthesiologists (ASA) classification score of 2 and had a Mallampati airway grade of 2. The ASGE guidelines do not support the use of monitored anesthesia care in a patient who does not have significant health conditions nor airway concerns. The guidelines suggest there is high quality evidence to support the use of mild-to-moderate sedation in healthy uncomplicated endoscopy procedures, which was the case with this patients procedure. Based on these findings, the anesthesia services were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for evaluation of current temporomandibular joint (TMJ) splint for adjustment or replacement. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested service. In general, conservative treatment for TMJ disorder is the first-line therapy for affected patients. This includes splint therapy. The patient has had success with splint therapy in the past. In this clinical setting an evaluation of the patient by a provider with experience in the management of TMJ is medically necessary. Such a provider can make a decision on continuation with splint therapy and asses her current appliance. Final Result: The reviewer determined that the requested service 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 oral facial and maxillary 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 48-year-old male enrollee requested the LifeVest wearable cardioverter for medical treatment of his medical condition.  Findings:  The physician reviewer found that based on the medical records provided for review, this patient had an acute myocardial infarction, complicated by arrhythmias requiring defibrillation. However, there was no documentation of arrhythmias beyond 24 hours from the acute infarction and no documentation of syncope, sustained or inducible ventricular tachycardia or aborted sudden cardiac arrest.  In this circumstance arrhythmias during the first 24-48 hours of an acute myocardial infarction are generally not predictive of subsequent sudden cardiac arrest. At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed or needed to be significantly delayed, such as due to infection or required explantation. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition.