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

The patient was diagnosed with osteoarthritis (OA) of the left knee, left knee joint pain, and left knee chondromalacia. The provider noted the patient underwent left knee arthroscopy. He previously had been treated with left knee corticosteroid injections. The patient reported left knee pain, difficulty bearing weight, and difficulty ambulating. Physical examination findings revealed that left knee range of motion was 5 to 120 degrees with pain and crepitus. The patients recorded weight was 270 pounds with a body mass index (BMI) of 34.67. The records document that his prior treatment included physical therapy and medications, including meloxicam, tramadol, and hydrocodone-acetaminophen. The patient requested authorization and coverage for Euflexxa injections for the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. Researchers reported that intra-articular hyaluronic acid (IAHA) injections provide a symptomatic benefit for patients with knee osteoarthritis without major safety concerns. IAHA offers one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, gain in quality-adjusted life years and substantial delays in time to total knee replacement. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections for the left knee are medically necessary for the 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 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 58-year-old female enrollee has requested speech therapy for the treatment of her viral encephalitis. Findings:  Two physician reviewers found that there is medical literature that supports the use of cognitive rehabilitation therapy for patients with prior cerebral injury, such as what occurs in viral encephalitis. The above referenced articles provide examples of how cognitive rehabilitation therapy has been used in similar cases and the benefit that it provides to patients with cerebral injury. In clinical practice, these therapies are essential to help patients return to a near-normal functional lifestyle. This patient clearly has verbal symptoms and warrants such therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. Findings:  The physician reviewer found that records provided for review document that this patient has a history of melanoma. Pathology revealed melanoma of 2.1 mm extending to the specimen periphery and base. The patient underwent testing with DecisionDx-Melanoma to assess for likelihood of metastasis and/or recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state that gene expression profiling tests may provide information on individual risk of recurrence, as an adjunct to standard American Joint Committee on Cancer (AJCC) staging for patients with melanoma (Chan, et al.). However, the currently available prognostic molecular techniques have not been demonstrated to yield superior health outcomes when compared to standard pathologic staging procedures. Moreover, the use of gene expression profiling requires further prospective evaluation in large, contemporary data sets of unselected patients. Overall, the DecisionDx-Melanoma genetic test would not have been recommended to change the management of this patients disease in lieu of standard risk profiling and testing. All told, the DecisionDx-Melanoma genetic testing 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 DecisionDx-Melanoma genetic testing 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 reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology 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: Upheld

A 51-year-old female enrollee has requested vaginal surgery for the treatment of her bladder problems. Findings:  The physician reviewer found that the treatment options for stress urinary incontinence (SUI) include surgical, pharmacologic, pelvic floor strengthening rehabilitation, and a combination of these options. However, it is extremely important that a firm diagnosis of SUI be made in order to have acceptable outcomes, as conditions other than SUI, or those in conjunction with SUI, may be present. The patients history, physical, and pelvic examination are crucial to evaluating these differential diagnoses. Urodynamic testing is an important component to the workup and standard of care. Cystoceles will commonly cause pelvic pressure and related symptoms, as well as predisposition to cystitis. The mere presence of a cystocele is not firm evidence of SUI; a urodynamics study is required to confirm the diagnosis of SUI. The urodynamics testing in this case did not support the presence of SUI. The history and pelvic examination do not support the diagnosis of a symptomatic cystocele, rectocele or enterocele. The proposed procedures for SUI, cystocele, rectocele and enterocele are therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a fifteen year-old male with a history of substance abuse is requesting reimbursement for the patients previous residential stay as well as authorization for additional residential treatment services.Reviewers Findings:The reviewing physician found that the submitted clinical records do not demonstrate the patients residential treatment services were medically necessary. Nor is there any indication for the patients return to a residential level of care.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 1-year, 10-month-old female enrollee has requested for speech therapy for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that the use of speech therapy significantly helps these patients communicate and learn to function since they have delays in their developmental attainment of milestones. Speech and language pathologists use different approaches to treat apraxia of speech, and no single approach has been proven to be the most effective. Therapy is tailored to the individual patient and is designed to treat other speech or language problems that may occur together with apraxia. Each patient responds differently to therapy, and some make more progress than others. Patients with apraxia of speech usually need frequent and intensive one-on-one therapy. Support and encouragement from family members and friends are also important. Consistent with these findings, the requested speech therapy is medically necessary and should be provided to this patient to address her speech and language delays.
Appeal type: Urgent Care
Decision: Upheld

A 48-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that The patient was diagnosed with bronchitis, prescribed an oral antibiotic and inhaler, and discharged.The prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms were not sudden on onset but had been present for at least 5 days. Although the patient reported mild shortness of breath, her pulse and respiratory rate were normal, her oxygen saturation was 100%, and she was not exhibiting any signs of respiratory distress. No emergent medical intervention was required in the emergency department.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested  residential treatment for the enrollees polysubstance dependence, major depressive disorder, anxiety disorder, not otherwise specified, and parent-child relational problems.   Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this patients case.  Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, sobriety, family harmony and mental wellness.  Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescents with substance dependence with psychiatric comorbidity and family problems represents a challenging endeavor.  In this patients case, she had failed treatment in the outpatient setting.  She also lacked an environment and support network conducive to sobriety.  Her previous residential placements were too short to garner the benefits of the treatment setting, and she promptly relapsed at the intensive outpatient level of care as she had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  This patient poses a significant risk to self, and possibly others, due to her drug use, impulsivity, anxiety, and mood symptoms.  Placement at the residential setting, with the comprehensive services and 24-hour structure afforded by the setting, was and is medically indicated.  All told, residential treatment provided from the time frame specified was and is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested authorization and coverage for magnetic resonance spectroscopy (MRS) of the prostate for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that the patient presented with an elevated PSA of 5.7 and a palpable nodule present in the prostate. The patients urologist recommended the patient undergo a biopsy for further evaluation, but the patient has requested a magnetic resonance spectroscopy (MRS) of his prostate prior to considering a biopsy. The Health Plan has denied this request, indicating that the requested diagnostic imaging is not likely to be more beneficial for evaluation of the patients medical than other available standard diagnostic procedures. Although MRS may be useful in the triage of patients with suspected prostate cancer and/or patients who have previously had a negative biopsy, the data available in the peer reviewed medical literature has not demonstrated that MRS can rule out clinically significant prostate cancer. Thus, MRS prior to a prostate biopsy has not been proven to eliminate the need for a needle biopsy or significantly improve the accuracy of a needle biopsy. Additionally, the current available clinical studies are small in sample size and control groups were often not used. Thus, further large, multi-center, double-blind, controlled studies are needed to determine the efficacy of MRS as a diagnostic tool in the evaluation of prostate cancer. The Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy (CPT code H2019) In the medical literature, Orinstein and colleagues reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors reported that the age at which ABA therapy was started and duration of treatment was correlated with outcome. The records provided for review document that this patient has been approved for 30 hours of one-to-one direct ABA services, which is an appropriate level of service. The patient has had a significant decrease in behaviors since ABA therapy was introduced. Moreover, there has been a plateauing of progress over the past few months. Given these findings, the ABA therapy (CPT code H2019) was not and is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 pediatrics with special qualification in pediatric 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam radiation therapy (PBRT) for treatment of his metastatic squamous cell carcinoma of the neck with unknown primary.  Three physician reviewers found that proton beam radiation therapy is not likely to be more effective for this patient than other available options. There is a lack of evidence to suggest that treatment of the patients head and neck cancer with proton beam radiation therapy will be more beneficial than standard treatment with photons and intensity modulated radiation therapy (IMRT). The National Comprehensive Cancer Network (NCCN) guidelines state that standard therapy for treatment of head and neck cancer is IMRT. The American Society of Radiation Oncology (ASTRO) emerging technology committee specifically stated that there is insufficient data to recommend proton therapy for routine head and neck radiation outside of clinical trials. Moreover, a recent review article stated that there are no major comparative clinical studies or randomized trials between proton and photon therapy in the treatment of head and neck cancer. The vast majority of patients with head and neck cancer are able to tolerate treatment with photon therapy with no major complications and there is insufficient data to suggest that outcomes are improved with proton treatment. For these reasons, treatment with proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment 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 radiation oncology 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: Overturned

The parent of a 14-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of the enrollees panhypopituitarism. Findings:  The physician reviewer found that this patients growth chart shows that his growth in height has deteriorated. He has had repeated low levels of the growth hormone dependent IGF-1 and IGFBP-3. In January 2010, his height had declined to the 10th percentile. The patient meets clinical indications for growth hormone therapy. He is lacking growth hormone and, without it, his height will continue to decline. Given the clinical situation and repeatedly low levels of IGF-1 and IGFBP-3, growth hormone stimulation tests are not required to establish the medical necessity of growth hormone for this diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested for a duplex Doppler scan of the right lower extremity for evaluation of her lower extremity pain. Findings:  The physician reviewer found that the majority of venous scans ordered to rule out deep vein thrombosis are not performed on patients with evidence of varicose veins.  Duplex Doppler scans are medically indicated when there is a high clinical probability of deep vein thrombosis.  The current medical evidence supports the requested services, as duplex Doppler scans are useful for diagnosing deep vein thrombosis.  All told, the requested duplex Doppler scan of the right lower extremity is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 14-year-old female enrollee has requested speech therapy for treatment of the enrollees apraxia. Findings:  The physician reviewer found that the records provided do not demonstrate that the additional therapy provided the patient greater benefit than the benefit she was already receiving. Furthermore, the records provided do not demonstrate that this patient required further therapy or that the therapy she was receiving was in some way lacking.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-old male has requested speech therapy at a frequency of 2 sessions per week for 60 minutes per session for treatment of his speech delay.  Findings:  The physician reviewer found that this child has identified delays in his receptive speech of 40 to 50% and his expressive speech of 70 to 80%, with deficits in his pragmatic speech of 40 to 50%.  Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, the requested speech therapy of 2 sessions per week for 60 minutes per session is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested a diagnostic cast model and oral surgical splint and temporomandibular joint manipulation with arthrocentesis for medical treatment of her temporomandibular joint arthralgia and dysfunction.  Findings:  The physician reviewer found that  given her symptoms and history, treatment with arthrocentesis and oral appliance was medically appropriate and consistent with accepted standards of care.  Arthrocentesis has been shown to be a very effective, minimally invasive technique for treatment of temporomandibular joint pain and acute closed lock conditions.  Fabrication of a splint for this patients condition was also medically indicated.  All told, the diagnostic cast model and oral surgical splint service and temporomandibular joint manipulation with arthrocentesis are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested a stem cell transplant for treatment of her multiple sclerosis. Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other treatment options.  This patient has severe and progressive disease that has been refractory to standard therapeutic approaches.  Although not a first-line therapy for multiple sclerosis, there is medical data that supports the requested services in aggressive cases of multiple sclerosis.  There is medical literature that documents autologous stem cell use in sustaining treatment free period, improving quality of life, and stabilizing or improving disease.  Given that the patient has failed most standard therapy, the requested stem cell transplant is likely to be superior over other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A forty-three year-old male who underwent resection of a right breast lump is requesting authorization of left breast liposuction.  Reviewers Findings:  The reviewing physician found that the patient has slight breast asymmetry, however the record does not document related functional problems, a concern for malignancy or significant pain requiring analgesics.  The reviewing physician found that the Health Plan denial should be upheld.