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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested mental health residential treatment services for treatment of his behavioral health condition.  The physician reviewer found that the mental health residential treatment services were medically necessary for treatment of the patients medical condition. In this case, the patient has diagnoses of school avoidance, ODD, autism spectrum disorder, ADHD and depressive disorder with risk to self or others. The patients behavioral conditions continued despite outpatient services which included individual psychotherapy, family therapy and medications. According to Chamberlain a residential treatment center only should be considered for families who are not able to provide therapy at home or at school. In-home services are preferable to residential placement and are often sponsored by state and local child welfare agencies. In addition, the American Academy of Child and Adolescent Psychiatry guidelines state that Day treatment, residential, and hospitalization facilities may need to be considered if the family is unable or unwilling to collaborate with the treatment of a more severe case of ODD. In this case, the patient failed multiple attempts at lower levels of care as well as inpatient admission. Given the patients history including the clinical documentation provided, residential treatment was medically necessary and appropriate in this clinical setting and consistent with standards of good medical practice. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The primary prevention guidelines for the management of cardiac risk and dyslipidemia currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For the reasons provided, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 58-year-old female enrollee has requested for abdominal corrective surgery for treatment of her status post excision of a pelvic mass. Findings:  The physician reviewer found that abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward.  It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons. Further, the requested service does not qualify as reconstructive surgery, as the patients condition does not constitute an abnormal structure of the body.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for external mobile cardiac telemetry. This patients records document a history of near syncope and palpitations. Evaluation with an echocardiogram revealed normal biventricular wall thickness, chamber size, diastolic and systolic function, with an ejection fraction of 55-60%, and 24-hour Holter monitoring was negative. The patient underwent further evaluation with external mobile cardiac telemetry. However, there is a lack of support in the peer-reviewed medical literature for the use of external mobile cardiac telemetry for evaluation of this patients symptoms, especially given the results of the previous work-up. The available clinical trials do not report improved clinical outcomes associated with the use of external mobile cardiac telemetry in lieu of patient-activated, external loop monitors in the detection of infrequent cardiac arrhythmias. All told, the external mobile cardiac telemetry was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the external mobile cardiac telemetry was not likely to have been 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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: Experimental/Investigational
Decision: Upheld

A 36-year-old female with a history of metastatic endometrial (endometroid histology) cancer, metastatic to visceral organs, who is also receiving Topotecan, requests authorization for Herceptin.Reviewers Findings:The three reviewing physicians found that there is insufficient evidence in the relevant medical literature to support the proposed use of Herceptin in this case. The combination of Herceptin and Topotecan has not been explored in the treatment of gynecological (endometrial) cancers. Given that Herceptin has no proven benefit in the situation, and in fact carries some associated risk, its use in this case is not recommended.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old male enrollee has requested platelet rich plasma injection for treatment of his torn labrum.   Findings:  Three physician reviewers found that there is inadequate scientific data that PRP injections are beneficial as an adjunct to surgical treatment of femoral acetabular impingement with labral tearing. Specifically, there is limited evidence demonstrating clinical benefits with the use of PRP for symptomatic osteoarthritis, either alone or as an adjunct to surgical procedures, in the management of articular cartilage pathology. Thus, there is a lack of support for the PRP injections provided to this patient during the hip surgery performed on the date indicated. The services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Xifaxan. The enrollee has B-cell lymphoma, irritable bowel syndrome and gastroesophageal reflux disease. The enrollee was treated with a two-week course of Xifaxan one year prior for small intestinal bacterial overgrowth. On a return visit, the enrollee reported returning symptoms of bloating and diarrhea. A breath test was positive for small intestinal bacterial overgrowth. After treatment with Xifaxan (rifaximin) last year, her symptoms of bloating improved. After an endoscopy, the patient complained that her prior bloating issues have returned. Literature reports that Xifaxan (rifaximin) has been shown to normalize the hydrogen breath test and improve symptoms in small intestinal bacterial overgrowth. A governmental body has provided prescribing information for Xifaxan (rifaximin). For enrollees with irritable bowel syndrome, the dosage is 550 milligrams, three times a day, for 14 days. This enrollee has a diagnosis of irritable bowel syndrome and small bowel intestinal overgrowth. Xifaxan (rifaximin) has helped her in the past. The medical literature and prescribing information both support repeating the treatment in enrollees with relapse.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested left knee platelet rich plasma (PRP) injections for treatment of the enrollees osteoarthritis with complex degenerative tear of the anterior horn and body of the lateral meniscus and chondromalacia patella.  Findings:  The physician reviewer found that based on the available documentation, it is not medically necessary for this patient to receive left knee PRP injections for treatment of left knee pain. There are general concerns as to the efficacy of PRP injections. Consistent with the weak support for efficacy of the use of PRP, the American Academy of Orthopaedic Surgeons has not recommended for or against the use of PRP in treatment of symptomatic osteoarthritis of the knee. Similarly, Moraes and colleagues concluded that there is currently insufficient evidence to support the use of PRP for treating musculoskeletal soft tissue injuries.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 42-year-old male with a history of back pain with radiation. His physician indicates the patient tried physical therapy and other treatments without success. In August 2004, the patient was provided a Saunders lumbar traction unit. The patient indicates the device helped reduce his pain. The Health Plan has denied reimbursement for the equipment at issue on the basis that it is considered experimental for treatment of the patients medical condition.The patient received an appropriate course of physical therapy without change in symptoms beyond the use of traction. Unfortunately, the available literature does not support use of traction for treatment of lower back pain. There is no evidence that the Saunders lumbar traction unit is superior to standard pain management modalities for treatment of patients such as this patient. As such, I have determined that the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 42-year-old man who has had a long history of back pain. He has tried several modalities without relief. He has been using a Saunders lumbar traction unit since August 2004 at the recommendation of his physician. The patient reports the lumbar traction unit has helped with reduction of his pain. He has requested reimbursement for the equipment at issue. The Health Plan has denied the patients request. The Health Plans denial should be upheld. There is no data to suggest that the Saunders lumbar traction unit is effective for the treatment of chronic low back pain. To date, no Class I data exists. Lumbar traction for the treatment of low back pain is of unproven efficacy at this time. Therefore, I have determined that the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 42-year-old male with low back pain who was treated with physical therapy without relief. In August 2004, the patient began using the Saunders lumbar traction unit. The patient indicates he has benefited from use of this equipment. The patient has requested reimbursement for the equipment at issue. The Health Plan indicates the efficacy of the Saunders lumbar traction unit has not been established in peer-reviewed literature. Review of the current medical literature reveals the efficacy of lumbar traction for treatment of low back pain has not been established. There is no randomized, placebo-controlled, peer-reviewed literature to support the use of the Saunders lumbar traction unit for treatment of this patients pain. The patient would have been more likely to benefit from a proactive physical rehabilitation program. Therefore, I have determined that the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 25 hours per week of individual therapy in an intensive outpatient program (IOP) and equine assisted psychotherapy for treatment of the enrollees post-traumatic stress disorder (PTSD), military sexual trauma, and chronic depression. Findings:  The physician reviewer found that based on the review of the available records, it has been noted that the patient has PTSD, military sexual trauma, and chronic depression. She has been undergoing treatment in the form of psychotherapy and medication management. The records do not specify the number of sessions of outpatient psychotherapy completed or evidence of objective functional improvement with the same. The documentation does not justify the clinical need for a higher level of care at this time as the records do not provide information regarding details of past treatment failures. Further, there is a lack of evidence that the patients psychosocial functioning has become impaired by moderate or severe symptoms of a mental health condition, and treatment cannot be adequately managed in a lower level of care. The request for authorization and coverage for 25 hours per week of individual therapy in an IOP and equine assisted psychotherapy is not medically necessary for treatment of this patients medical condition. 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 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 patient is a 68-year-old female who underwent lower extremity bypass for a non-healing foot ulcer.  Postoperatively, the wound did not heal and her provider prescribed an ArtAssist compression device.  The wound reportedly healed completely with the use of the device.  The patient now requests reimbursement for the ArtAssist device.  The Health Plan does not consider the device medically necessary and has denied coverage.A review of the current literature, including the articles cited at the manufacturers website, reveals numerous case studies, case series, and basic science studies regarding the use of the ArtAssist device. These studies show that the device may increase blood flow to the lower leg. The case series reports instances of wound healing after application of the device. However, there are no randomized, prospective studies that show the ArtAssist device produces a greater benefit than standard therapies in cases of ischemic wounds.  The only two randomized, prospective studies that exist concerning this device show some benefit for patients with claudication. Although claudication is also a result of chronic limb ischemia, the patterns of disease and pathophysiology of patients with tissue loss and patients with claudication are not directly comparable. Therefore, the two randomized studies showing benefit in claudicants cannot be directly applied to patients with tissue loss. Until randomized, prospective trials show benefit in patients with ischemic wounds, the technology should be considered experimental/investigational for this indication. Experimental/investigational measures may be appropriate only when other non-experimental treatments have failed. In this case, hyperbaric oxygen (HBO) therapy is a treatment that is considered non-investigational for this patients condition, and it was not tried prior to the application of the ArtAssist device. Therefore, I have determined the device at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of digital breast tomosynthesis to the standard digital breast mammographic may result in decrease in call backs and increase in detection of small tumors.  Per the medical literature, the addition of tomosynthesis to standard mammographic views is more advantageous than digital mammography alone.  All told, breast tomosynthesis was likely to have been more effective 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 diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panitumumab in liquid intravenous (IV) form. Panitumumab is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with wild-type RAS metastatic colorectal cancer, either as first-line therapy in combination with folinic acid, fluorouracil, oxaliplatin (FOLFOX) or as a single agent following disease progression after prior treatment with fluoropyrimidine, oxaliplatin, and irinotecan containing chemotherapy. Panitumumab is not indicated for the treatment of patients with RAS-mutant metastatic colorectal cancer or for in patients with an unknown RAS mutation status. This patient has no documentation of KRAS or NRAS mutation status. In addition, his performance status does not support treatment with additional chemotherapy. All told, panitumumab in liquid IV form is not medically necessary for treatment of this patient.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 reviewer is board certified in internal medicine with subspecialty certifications 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of 3-year-11-month-old male enrollee has requested reimbursement and continued authorization and coverage for speech therapy services provided from a specific date and forward.  Findings:  The physician reviewer found that Childhood apraxia of speech (CAS) is a serious childhood speech deficiency.  Lewis, et al. studied 10 children with CAS who were diagnosed at age 4 and reassessed at age 10.  At age 10, their improvement was limited compared to children with other speech disorders; additionally they demonstrated serious deficiencies in reading and spelling.  The authors recommended intensive speech therapy for patients diagnosed with CAS.  Additionally, there is a significant medical literature supporting speech therapy in the three plus age group. Speech therapy is considered necessary and efficacious in children over the age of three with articulation and speech dysfunction (Tyler; and Sharp and Hillenbrand).  In the case of this patient, a repeat speech evaluation is not necessary, as he underwent an extensive evaluation approximately six months ago.  It is common in the medical community to refer a child with CAS for speech therapy, especially when there is literature supporting that these children have a high probability of retaining CAS for many years.  In sum, the submitted documentation supports the medical necessity of two hours weekly of individual speech therapy, starting from the date in question and forward.