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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that according to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis used to perform the breast examination was likely to have been more effective than other methods of evaluating this patient for breast cancer.Final Result: Two 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for  speech therapy for treatment of the enrollees delays in expressive and receptive language skills. Findings:  The physician reviewer found that according to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  In this patients case, he demonstrates significant expressive language delay that is negatively impacting his ability to communicate in a functional and age-appropriate manner. Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of his medical condition. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with a history of plaque psoriasis and is requesting treatment with Otezla. However, there is no documented intolerance to or lack of efficacy of treatment with methotrexate or acitretin. Additionally, the patient has not tried and failed treatment with either phototherapy or Stelara. There are no documented contraindications to use of either of these treatment modalities. Given that the patient has no documented contraindications to the therapies listed above, the request for coverage of Otezla is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication 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 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: An enrollee has requested reimbursement for genetic laboratory testing (CPT 81240  coagulation factor II prothrombin; CPT 81241  coagulation factor V Leiden; and CPT 81291  5,10-methylenetetrahydrofolate reductase (MTHFR). This patient experienced preterm contractions at 19 weeks gestation while traveling. She presented to a local provider for evaluation. In addition to routine obstetrics laboratory testing, she underwent testing for inherited thrombophilias. The patient reports that her provider recommended testing given her painful contractions to ensure that her pregnancy did not deteriorate. However, there is a paucity of peer-reviewed medical literature or guidelines supporting a clinical role for the testing performed in patients who present with preterm contractions. According to the American College of Obstetricians and Gynecologists (ACOG), there is a lack of support to establish a causal link between inherited thrombophilias and adverse pregnancy outcomes. ACOG noted that screening for antiphospholipid antibodies might be appropriate in patients experiencing fetal loss, defined as three spontaneous losses. This patient did not meet the definition of recurrent miscarriage since this is her first pregnancy. In addition, the records do not report concern for inherited thrombophilia based on recurrent, unexplained late fetal loss associated with evidence of placental ischemia and maternal vessel thrombosis. Moreover, the available data does not support screening for presence of the MTHFR variant in asymptomatic patients. An extensive literature review has shown a lack of association of heterozygosity of the MTHFR mutation and miscarriage. All told, the genetic laboratory testing (CPT 81240  coagulation factor II prothrombin; CPT 81241  coagulation factor V Leiden; and CPT 81291  MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the genetic laboratory testing (CPT 81240  coagulation factor II prothrombin; CPT 81241  coagulation factor V Leiden; and CPT 81291  MTHFR) 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 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 obstetrics and gynecology 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: The patient has requested authorization and coverage for bariatric surgery. The records provided for review document that this patient is morbidly obese and may benefit from bariatric surgery. However, a dietary evaluation that includes education and understanding of nutritional and dietary changes and appropriateness for candidacy for bariatric surgery has not been documented. The dietary evaluations provided for review are for weight management and do not detail any understanding of post-bariatric diet and follow-up, or the need for micronutrient supplements. In the absence of this nutritional evaluation as part of a multidisciplinary evaluation to determine candidacy for bariatric surgery, the records do not support an indication for the requested surgical intervention. Accordingly, the requested bariatric surgery is not medically necessary for 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 minimally invasive and bariatric 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implant removal and breast lift. Researchers noted that, Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. The American Society of Plastic Surgeons (ASPS) supports reduction mammaplasty for patients based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life. This patient complains of full body pain with no clear etiology. She complains of arthralgias, back pain, myalgias, neck pain and stiffness, in addition to chronic bilateral lower back pain with right-sided sciatica. However, there is no documented history of back, shoulder, and neck pain related to breast weight. There is no report of shoulder grooving or submammary rash demonstrated in the photographs reviewed. There is a lack of report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. In the absence of at least two quality of life signs, the requested implant removal and breast lift are not supported by ASPS guidelines as medically necessary. The patient underwent cosmetic breast augmentation in 2015 with 500 mL smooth silicone gel prostheses. She now would like for her breasts to be smaller with a prepartum appearance, and she is willing to undergo implant removal in order to accomplish this goal. She has a complex pain history that is not supported by clinical history or physical examination to be related to her breast implants. The records support that the patient has breast enlargement and ptosis as a result of the previous cosmetic placement of 500 mL breast implants. The amount of breast tissue that is proposed to be resected for the breast lift is 115 grams on her larger breast, and less on her smaller breast. The removal of 115 grams does not support that breast weight is the cause of pain or functional symptoms. For these reasons, the requested implant removal and breast lift are not medically necessary for the 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 plastic 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

A 37-year-old female enrollee has requested Nuvigil for treatment of her multiple sclerosis. Findings:  Two physician reviewers found that there have been mixed results in well designed clinical trials on the efficacy and safety of Nuvigil for multiple sclerosis. In addition, there have been no well designed clinical studies demonstrating the long-term safety and effectiveness of Nuvigil for patients with multiple sclerosis. Given the lack of adequate evidence for Nuvigil in patients with fatigue related to multiple sclerosis, its use is not likely to be more beneficial than other therapies for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prolia injections every six months. Findings:  The physician reviewer found that Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis, Prolia reduces the incidence of vertebral, non-vertebral, and hip fractures. In this case, there is a history of wrist fracture and worsening of osteoporosis despite treatment with other agents. As such, the request for Prolia is medically appropriate. Therefore, Prolia injections every six months are medically necessary for the treatment of this patient. 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 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: Medical Necessity
Decision: Overturned

The parent of a 5-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 35 hours per week for treatment of the enrollees global developmental delay and autism spectrum disorder.  Findings:  The physician reviewer found that Based on review of the available records, both the patients pediatric neurologist and her clinical psychologist diagnosed her as autistic and independently recommended 20 to 35 hours of ABA therapy. The patients intellectual disability is a frequent co-morbid diagnosis in autistic children. However, this condition does not preclude the patient from benefitting extensively from ABA therapy. ABA therapy is well-documented as the only consistently successful intervention for autistic children. The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a documented 40-year track record of substantially improving motor, verbal, and socially interactive skills in autistic children. Myers and Johnson indicate that the effectiveness of ABA-based intervention in autism spectrum disorder has been well-documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Further, the authors report that, children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. This patient has been diagnosed as autistic, for which ABA therapy is the well-documented therapy of choice. There is consensus among clinical psychologists that ABA therapy should be intensively initiated as soon as a diagnosis of autism is established. With regard to the appropriate frequency of ABA therapy, at the requested 35 hours per week of ABA services, there would be inadequate time to develop group socialization or trials of mainstreaming the patient during school hours. A frequency of 20 hours of ABA therapy per week is more appropriate in this setting. All told, it is medically necessary that ABA therapy be continued for this patient. However, the recommendation is for 20 hours of ABA therapy per week.
Appeal type: Medical Necessity
Decision: Upheld

An 83-year-old female enrollee has requested Letairis for treatment of her pulmonary hypertension. Findings:  The physician reviewer found that currently, pulmonary vasodilators are indicated for treatment of patients with WHO group I pulmonary hypertension and not those who have WHO group II pulmonary hypertension (pulmonary hypertension associated with left heart disease).  The records document left heart disease as a possible cause of this patients pulmonary hypertension. There is no record of cardiac catheterization to confirm pulmonary artery pressures and to assess the contribution of left heart disease (i.e. no measurement of left ventricular end diastolic pressure).  Therefore, the submitted documentation does not substantiate the medical need for pulmonary vasodilators of any kind.  Additionally, there is no documentation that the patient has tried the Health Plans preferred drug Tracleer.  There is a lack of sufficiently well-controlled clinical data that supports a significant difference in clinical outcomes between these two medications.  All told, Letairis is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient is nearly two-years of age but has not developed the ability to orally communicate. Although this patient does not have a diagnosis of autism, without professional intervention, he may not develop any understandable speech for many years. In the medical literature, Norbury and colleagues reported that the parental checklist is an extremely reliable diagnostic tool in toddlers with speech delay, thus, the patients failure to communicate should be accurately described. In addition, Emmanuel and colleagues concluded that a therapists initial impression of a patient tends to be remarkably accurate in long-term follow-up of very young children with speech delay. With regard to treatment, Landa found that the earlier intervention is initiated for speech delay, the better a patients prognosis. This patients problem is organic, as it is the failure of the normal axonal frontal-temporal-brainstem cerebral pathways to develop. Consistent with the recommendations in the clinical studies, it is medically indicated that this patient receive 1 to1 speech therapy to address his speech and language delay.
Appeal type: Urgent Care
Decision: Overturned

The representative of a 53-year-old deceased male enrollee has requested for ambulance transport services for treatment of the enrollees terminal bladder cancer. Findings:  The physician reviewer found that this patient had a bowel obstruction, which can cause abdominal distension, pain and vomiting. Given these risks, transport of the patient in a supine position was necessary. All told, given that the patient was still in considerable pain and that he was on oxygen at the time of transport, the ambulance transportation at issue was medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical spinal fusion (arthrodesis) surgery for treatment of her recurrent neck pain with radiation to bilateral shoulders. Findings:  The physician reviewer found that the submitted medical records do not support the medical necessity of cervical fusion surgery for this patient. The patient does not meet established criteria for cervical fusion surgery. Upon review of the submitted records, there is no evidence the patient has documented instability, fracture or tumor. This patients magnetic resonance imaging (MRI) results do not show severe nerve root impingement or cord compression, as required by guidelines. Furthermore, the patients records do not provide confirmatory evidence that the patient is myelopathic. All told, the patient does not meet accepted clinical indications for cervical spinal fusion (arthrodesis) in this case. As such, the requested procedure is not medically necessary for treatment of the patients recurrent neck pain.Final Result: The reviewer determined that the requested procedure is not medically necessary 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: Overturned

A 59-year-old female enrollee has requested for Avastin for treatment of her non-small cell lung cancer. Findings:  Three physician reviewers found that Avastin is one of a new class of drugs that inhibit tumor angiogenesis. It has been approved when used with chemotherapy in several types of cancer. There is one study in non-small cell lung carcinoma demonstrating a two-month improvement in median survival when Avastin is combined with carboplatinum-taxol chemotherapy for metastatic disease. However, at this time there is no data demonstrating any advantage to the use of Avastin when it is combined with any other drugs including Alimta. Nor is there any evidence that continued use of Avastin will be effective at this point.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one year-old male who was born with Pierre Robin sequence and diagnosed with Stricklers syndrome is requesting authorization for ongoing pediatric ophthalmologic care with the out-of-network ophthalmologist.  Reviewers Findings:  The reviewing physician found that the submitted clinical evidence indicates the patients condition is stable to the point that care can be transferred to another pediatric ophthalmologist.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old male enrollee has coverage for the NESS  H200 functional electrical stimulator for treatment of his spinal cord injury.Findings:  The physician reviewer found the patient is clearly a candidate for NMES therapy to assist in his functional recovery. However, effective NMES can be supplied via conventional units. There is no documentation in case-controlled, peer-reviewed literature to show that the efficacy of the Bioness NESS H200 functional electrical stimulator is superior to conventional NMES therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee has requested for Rituxan infusion therapy for treatment of his multiple sclerosis.    Findings:  Three physician reviewers found that Rituxan is an anti-neoplastic monoclonal antibody used in treating rheumatoid arthritis. There is no evidence in the literature to support its use in RRMS. Rituxan remains an unproven therapy for the treatment of multiple sclerosis, as there is insufficient evidence in the peer-reviewed medical literature to support the long-term safety and efficacy of this drug for the patients diagnosis. As such, its superiority over other available therapies in this setting has not been established.