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

A 36-year-old female enrollee has requested for assistant surgeon services for treatment of her history of adhesions. Findings:  The physician reviewer found that this patient had multiple prior abdominal surgeries, including a colectomy.  Thus, extensive adhesions were present.  In terms of the hysteroscopy, she had multiple prior benign endometrial biopsies, and there was no history of abnormal bleeding to suggest other endometrial pathology.  In terms of the colposcopy, multiple prior evaluations were performed as an outpatient, with no report of any recent abnormal Pap smear.  Per current medical guidelines, neither a colposcopy nor a hysteroscopy generally require a surgical assistant, and the medical records do not demonstrate that an assistant surgeon was required for the services at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 49-year-old female with psoriasis that is complicated by psoriatic arthritis.  Per the records, her symptoms have not been controlled by first-line topical treatments. Her scalp lesions cannot be treated with light therapy, and acitretin, methotrexate and cyclosporine were not considered due to potential liver/renal toxicity. The patient has requested coverage for Humira. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Humira is medically necessary for the treatment of this patients medical condition. Psoriasis is a chronic inflammatory skin disease that presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis can have a negative impact on the quality of life, especially in patients with moderate or severe disease. Humira is Food and Drug Administration approved for the treatment of rheumatoid arthritis and is also used in treating other conditions, including psoriasis and psoriatic arthritis. Clinical studies and randomized controlled trials have shown the short-term efficacy of Humira in psoriatic arthritis and psoriasis. Humira has been shown to be effective therapy when used either continuously or intermittently at 40mg subcutaneous injections every other week. In patients resistant to conventional doses, the efficacy of Humira can be increased by dose escalation, such as shortening the dosing interval and increasing the amount of medication per single dose. Medical evidence supports the requested medication in this clinical setting. Therefore, Humira is 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 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested acute inpatient hospital services for treatment of her depression and post-traumatic stress disorder. Findings:  The physician reviewer found that the patient did not require inpatient care as of the date in question as her depression was not major and she presented no acute safety issues. She showed no serious withdrawal symptoms. The patient was stable and under control, and had reached probable maximum benefit by the date in question. She was appropriate for transfer to an outpatient level of care after the last authorized date of service.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Albinism Multigene Genetic Test Panel by Fulvent. This patient presents with albinism. His provider notes suspicion for oculocutaneous albinism type 1, given the reduced synthesis of melanin in the skin, hair and eyes associated with ocular features of nystagmus, reduced iris pigmentation and retinal pigment, and foveal hypoplasia with significantly reduced visual acuity. Clinical findings of hypopigmentation of the skin and hair, in addition to the characteristic ocular symptoms, are present in many syndromic disorders such as Hermansky-Pudlak syndrome. Due to the considerable phenotypic overlap of different types of oculocutaneous albinism, molecular testing using a multigene panel or comprehensive genome sequencing is preferred for a precise diagnosis. Some patients with clinical features of oculocutaneous albinism, but negative genetic testing, may have other unidentified types of oculocutaneous albinism. Molecular testing is likely to affect this patients management, surveillance, prognosis, and genetic counseling. For these reasons, the requested Albinism Multigene Genetic Test Panel by Fulvent is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  All of the three physician reviewers found the requested Albinism Multigene Genetic Test Panel by Fulvent is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested speech therapy for one hour per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of greater than 50% and speech therapy is indicated for any delay greater than 25%. An extensive review of the literature including meta-analysis by Law and colleagues demonstrates the positive effects of speech and language therapy interventions for children with expressive phonological and vocabulary difficulty. In addition, Volmar and Weisner indicate that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Further, approximately half of all children delayed at 2 years of age catch up to their peers by 3 years of age. All told, children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders and those who participate in speech therapy show better improvement than no treatment. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient has a history of extreme prematurity and speech delay. Consistent with the medical literature, ongoing treatment including speech therapy is crucial to help minimize his neurodevelopmental disabilities. For this reason, speech therapy is medically necessary for treatment of this patients expressive and receptive speech delays and should be approved at the requested frequency of one hour once per week.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested therapy.  As noted by Nelson and colleagues, identification of children at risk for developmental delay or related problems may lead to intervention when chances for improvement are best.  Per Law and colleagues, there is a positive effect of speech and language therapy interventions in this clinical setting.  This patient presents with expressive language delays that are negatively impacting his ability to communicate and interact with his environment. The literature supports the use of speech and language therapy to address expressive deficits and facilitate development of age appropriate communication skills.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female with a history of hip pain. She has been diagnosed with osteoarthritis. The patients physician recommended metal-on-metal hip surfacing, which the Health Plan has denied due to a lack of scientific evidence in peer-reviewed medical literature to support its efficacy.Metal-on-metal hip resurfacing is still in experimental/investigational studies. Short-term data is sparse, with no long-term prospective study establishing its effectiveness. In addition, the procedures risks are uncertain. Furthermore, there are other treatments available for this patient. At this time, metal-on-metal hip resurfacing cannot be recommended as there is very little data to warrant its general use. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested Melphalan autologous stem cell transplant for the treatment of his multiple myeloma. Findings:  Two physician reviewers found that there is a scant amount of data available regarding a third autologous stem cell transplant in this setting. National Comprehensive Cancer Network treatment guidelines indicate limited support for repeat autologous stem cell transplant. Two references were submitted with this appeal. A review of the published peer-reviewed literature revealed no other relevant studies. The submitted report by Jourdan and colleagues involves two patients who received a third transplant. The reference by Rokicka and colleagues reported on the planned triple transplant treatment of 13 patients who were quite ill with their myeloma. They were given modified doses of the high-dose chemotherapy and seemed to demonstrate reasonable, although not very long, responses. These patients are not representative of this particular patient in terms of patient history or the planned treatment. Furthermore, this patient experienced a shorter period of disease control after his second transplant procedure than after his first procedure. As such, it is expected that the period of disease control (if any) would be even shorter after a third transplant procedure. Moreover, there is a substantial risk of mortality associated with a third cycle of high-dose chemotherapy. In conclusion, there is insufficient evidence that the requested Melphalan autologous stem cell transplant will confer any benefit in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested neurofeedback (cognitive rehabilitation therapy) for the treatment of the her primary sleep disorder and post traumatic stress disorder (PTSD). Findings:  The physician reviewer found that the evidence supporting cognitive rehabilitation is not robust. The new information added for this review does not add any new light to the use of cognitive rehabilitation. According to the NIH (National Institutes of Health) consensus panel on rehabilitation of persons with TBI (traumatic brain injury), limited data is available on the effectiveness or cognitive rehab programs. Some studies support computer-assisted exercises. The role in mild TBI is not established. Ponsford, et al. found mild TBIs constitute 70-90% of all head injuries, most commonly the result of falls, motor vehicle accidents and sports- related injuries. The author found most cases resolve within 3 months, however, some patients continue to have difficulties (15-25%). The author found more uniform assessments needed to be established. There is insufficient evidence to support the use of cognitive rehabilitation in mild traumatic brain injury patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for DecisionDX-Melanoma genetic testing assay. The enrollee was diagnosed with cutaneous melanoma. She underwent the DecisionDX-Melanoma genetic testing assay. The enrollees physician reports current cutaneous melanoma management guidelines indicate post-surgical management should be tailored to an individuals probability or risk of recurrence. The risk classification provided by the DecisionDX-Melanoma test is used to better estimate an individuals risk of recurrence. This result helps determine appropriate surveillance, clinical follow-up and specialty referral. The DecisionDx-Melanoma gene panel is not currently recommended by any standard treatment guidelines. Providers may suggest that those who are shown to be at high risk for metastasis as a result of this test undergo more frequent clinical evaluations and imaging. However, if additional therapies are either contraindicated or not available, this categorization may increase anxiety without real benefit to the individual. This enrollee is not a good candidate for the DecisionDX-Melanoma genetic testing assay. Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Factor V Leiden mutation testing (CPT 81241).  Although no DVT was identified on duplex imaging, the patient did have an episode of superficial venous thrombosis (SVT). In response to this, the work-up was appropriate, given the patients age and non-smoker status. Subsequent genetic testing was recommended to determine whether patient is Factor V Leiden heterozygous or homozygous. This genetic testing was appropriate because the homozygous state carries much high thrombotic risk compared to the heterozygous state. The homozygous state may require therapeutic anticoagulation. Additionally, genetic testing was appropriate to identify the specific mutation in order to enable testing of the patients daughter. All told, the Factor V Leiden mutation testing (CPT 81241) was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Factor V Leiden mutation testing (CPT 81241) was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in general vascular 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a seven-month-old male enrollee has requested authorization and coverage for a cranial helmet/doc band including molding and fitting for treatment of the enrollees plagiocephaly.  Findings:  The physician reviewer found that Since the back to sleep campaign was recommended by the American Academy of Pediatrics (AAP), there has been an increase in the incidence of positional plagiocephaly in infants (Trachtenberg, et al). Tamber and colleagues reviewed 15 studies on the treatment of positional plagiocephaly in infants and concluded that there is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. Roby and colleagues evaluated 1,045 teenagers born after the introduction of the back to sleep recommendation and found persistent plagiocephaly in only 1.1% and brachycephaly in 1%, compared with the estimates of 20-48% incidence in infants, suggesting that positional plagiocephaly may self-correct over time. Given this support, the requested cranial helmet/doc band including molding and fitting is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 pediatrics and neurology with special qualification in child neurology 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: The patient has requested authorization and coverage for laser hair removal on the face and neck. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that for some patients, interventions such as rhinoplasty or facial hair removal can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Facial hair removal is one of the most common treatments for gender dysphoria for transgender females, to reduce distress as well as to help with social functioning in living as a female. Coleman and colleagues noted that hair removal through electrolysis, laser treatment, or waxing is an effective treatment to help alleviate gender dysphoria. As this patient has documented distress related to the presence of masculine facial hair, the requested laser hair removal on the face and neck is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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 psychiatry 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

The parent of a male enrollee has requested the addition of a new speech goal of K and G articulation to the enrollees speech therapy treatment plan for treatment of the enrollees autism spectrum disorder and speech delay.  Findings:  The physician reviewer found that a study by Lousada and colleagues showed that only focusing on articulation goals did not produce the same results on intelligibility as focusing on speech strategies to improve phonologic processing and overall intelligibility. In this case, the patient is receiving an appropriate amount of speech therapy with adequate treatment goals to address his intelligibility and his pragmatic language deficits. As such, the addition of a new speech goal of K and G articulation to the patients speech therapy treatment plan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested alprazolam and/or clonazepam for medical treatment of his attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The current medical evidence does not support alprazolam and/or clonazepam in this clinical setting.  The use of alprazolam and/or clonazepam in such high doses for the treatment of attention deficit/hyperactivity disorder poses a risk to the patients health.  The requested medications are not in accordance with generally accepted professional standards of practice and are not consistent with the standard of care in the medical community for the treatment of this patients condition.  All told, alprazolam and/or clonazepam are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested betamethasone valerate (Valisone) 0.1% cream for treatment of her eczema.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. This patient has a long-standing history of eczema and has been maintained on medication for years, but there are likely newer medications that she has not yet tried that are safer in the long-term, including the non-steroidal ointment tacrolimus (Paller et al and Takeuchi et al). There is no medical reason why the patient should only use one medication for her eczema.  Additionally, the Health Plan has suggested consultation with dermatology for other treatment options, which would likely be of benefit to this patient and should be pursued. For the reasons set forth above, betamethasone valerate (Valisone) 0.1% cream is not medically necessary for treatment of the patients medical condition.