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

Nature of Statutory Criteria/Case Summary:The parent of a 6-year-old male enrollee has requested authorization and coverage for one-on-one speech therapy, for 30 minutes per week for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that review of the records indicates the enrollee has an individualized education program (IEP). The records note that while the enrollee has had speech services through his school district, his parent feels that he has made very minimal measurable progress with this program. The enrollee is reported to have limited verbal communication with others, which is noted as affecting his relationships with peers and school activities.The submitted documentation supports the medical necessity of the requested therapy. Intelligibility of speech can be markedly impaired in individuals with Down syndrome. Yoder and colleagues have described how speech comprehensibility is malleable in school-age students with Down syndrome. According to Barbosa and colleagues, adolescents with Down syndrome who have speech-language therapy during vocational training experienced positive changes in social behavior, as evidenced by an increase in their autonomy and communication. In this case, while the patient has received group-based speech therapy in his school program, he has been documented to have made great progress since he began one-on-one speech therapy on 5/24/18. The medical literature also supports the value of speech-language therapy for individuals with Down syndrome. Under these circumstances, the requested one-on-one speech therapy, for 30 minutes per week, is medically necessary for treatment of the 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 overturned.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: An enrollee has requested authorization and coverage for Prolia injection (CPT code J0897) 60 mg, once every six months for a year.Medical literature supports that the requested medication is medically necessary. authors reviewed the pharmacology and major clinical trials and concluded that denosumab (brand name Prolia) is an efficacious and safe osteoporosis treatment option, with current data up to eight years of continued use showing continued improvement in bone density with sustained fracture risk reduction. They found that safety profiles overall are similar to placebo, with no new safety concerns in extension trials, though a theoretical increased risk of infection exists with receptor activator of nuclear factor-B ligand (RANKL) inhibition. Researchers have stated that although bisphosphonates remain the mainstay of treatment for osteoporosis and metastatic disease in woman with breast cancer, the ABCSG-18 trial showed that patients who started denosumab within 3 months of the start of aromatase inhibitors were the ones deriving more benefit from treatment. They noted that in the D-CARE trial, it was mandatory to start treatment no later than 3 months after surgery, so patients had the ideal time window to receive denosumab.In this case, the patient did not tolerate Zometa for her osteoporosis. She did not have an acute phase reactant situation with body aches lasting a few days, rather, she had body aches lasting a few weeks. Although the literature suggests that the flu-like symptoms and body aches which can occur with Zometa are not a class reaction, the patient experienced extensive, ongoing symptoms. For this reason, she should not have to take oral bisphosphonates prior to trying Prolia. Prolia would be a good option for this patient, who had extensive adverse effects with a bisphosphonate that extended beyond flu-like symptoms. Under these circumstances, the requested Prolia injection (CPT code J0897) 60 mg, once every six months for a year, is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, 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

A 45-year-old female enrollee has requested Procrit injections for treatment of her anemia.  Findings:  The physician reviewer found that Procrit is indicated for use in anemic patients undergoing elective surgery who are at risk of blood loss. Medical indications supporting the use of Procrit include having a hemoglobin level greater than 10, but less than or equal to 13.  This patient met these criteria. Procrit helps stimulate the bone marrows ability to produce red blood cells. By increasing the red blood cell supply before surgery, the hemoglobin level is increased and remains higher during and after surgery. The goal is to reduce the number of blood transfusions during and after certain major surgeries.  Studies have shown that when Procrit is given before surgery, patients produce additional red blood cells and have a significant increase in hemoglobin by the day of surgery.  They also require fewer transfusions.  Studies have suggested that for anemic patients, intravenous iron therapy may improve the dose-response relationship between erythropoietin therapy and erythropoiesis.  In this patients case, both intravenous iron therapy and Procrit were utilized.  This patient was additionally at increased risk for complications associated with blood loss given her medical history of hypertension.  Maximizing efforts to increase her preoperative hematocrit and to decrease operative blood loss are important considerations to help prevent the increased risks of cerebral or cardiovascular events.  All told, Procrit injections provided during the said time frame were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old man who has had two cysts, one of the anterior forehead and the other of the left temple for approximately 13 years. The patient states that the cysts are occasionally painful. The patient wishes to have the cysts surgically excised. The Health Plan has denied authorization for the requested procedure indicating that it is cosmetic in nature.The Health Plans denial should be overturned. The patient states that the cysts on his forehead and temple are sometimes painful. In cases where cysts are painful, surgical excision is medically indicated to improve function. Surgical excision of the patients symptomatic cysts is medically reasonable and appropriate and is not cosmetic in nature. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Orthovisc injections (J7324) in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of lasting benefit from prior injections administered since 2012. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections (J7324) in both knees are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardioverter defibrillator for three months. The wearable cardioverter defibrillator is indicated as a temporary therapy for patients with a high risk for sudden cardiac death (SCD). The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines on the management of patients with ventricular arrhythmias note that patients who may benefit from the temporary use of a wearable cardioverter defibrillator include: patients with a permanent implantable cardioverter-defibrillator (ICD) that must be explanted, or those with a delay in implanting a newly indicated ICD; patients with reduced left ventricular (LV) systolic function [a LV ejection fraction (EF) at or less than 35%] who have undergone coronary revascularization with coronary artery bypass graft (CABG) surgery in the past three months; patients with newly diagnosed nonischemic cardiomyopathy with severely reduced LV systolic function that is potentially reversible. Among patients with reduced LV systolic function who have had a myocardial infarction (MI) within the past 40 days, there is conflicting data on the benefits of a wearable cardioverter defibrillator as a primary prevention against SCD. In this case, the patient does not meet the criteria for patients who may benefit from the temporary use of a wearable cardioverter defibrillator. Therefore, a wearable cardioverter defibrillator for three months was not likely to have been more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the wearable cardioverter defibrillator for three months at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device at issue was not likely to have been more beneficial for treatment 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 sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 patient has requested reimbursement and prospective authorization and coverage for theta burst transcranial magnetic stimulation (TMS) services. Researchers concluded that about 20-30% of patients continue to experience pervasive depressive symptoms despite adequate trials of medication and psychotherapy. The authors noted that effective second-line therapies including TMS are viable options for treatment resistant depression. Moreover, the authors found that TMS protocols with repetitive TMS and theta burst stimulation have been shown to be effective, safe and tolerable. In one study on theta burst TMS, medical literature reported five of six patients qualified as responders, and four patients achieved full remission. In this case, the patient was previously treated with and either failed or was intolerant to multiple treatments for major depression. He continued to experience debilitating symptoms but showed a positive response to theta burst TMS. Given these findings, the theta burst TMS services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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: Overturned

An 18-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of his growth hormone deficiency. Findings:  The physician reviewer found that the patient demonstrates classic growth hormone deficiency, as manifested by short stature, low IGF-1 level, poor response to two provocative growth hormone tests, low bone density, delayed bone age and small pituitary on MRI. Growth hormone therapy is warranted until fusion of the growth plates, at which point the patient should be retested to assess whether he meets criteria for adult growth hormone deficiency. Retesting is not indicated at this point in time when the patient still has open epiphyses.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis (CPT codes 64636 and 64635) of the right side and prospective authorization and coverage for radiofrequency neurolysis of the left side.Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case. A study reviewed the efficacy of radiofrequency ablation of lateral sacral branches and found the evidence was insufficient to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy. The authors noted the need for additional research. Therefore, radiofrequency neurolysis (CPT codes 64636 and 64635) of the right side was not likely to have been superior over other treatment options. Additionally, radiofrequency neurolysis of the left side is not likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the services at issue were not and 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: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services on an emergent or urgent basis.  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a lesion on her face. It was not painful. There was no indication the lesion had suddenly worsened. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with a lesion on her face and assessed with pyogenic granuloma, which is a slow growing inflammatory vascular lesion that is not malignant. The patient was not experiencing any systemic symptoms or signs of acute infection such as fever or purulent drainage. Treatment could have been safely delayed until the patient returned to her service area. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male has requested coverage for past residential treatment services provided for treatment of his substance abuse.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) placement criteria, this patient was a candidate for treatment at a less restrictive level of care during the period under review. According to the ASAM placement criteria, the patient was not at risk for withdrawal, his symptoms were mild, and he had variable engagement in treatment, requiring a structured program several times per week to promote progress through the stages of change. Further, the patients recovery environment was supportive and he could safely be treated while residing at home or in a sober house. Thus, treatment at a lower level of care was indicated for this patient during the time frame at issue. As such, the residential treatment services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female has requested duodenal switch surgery for the treatment of her obesity. Findings:  The physician reviewer found that in the available scientific literature, the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. The Health Plan points to several alternative procedures (i.e., vertical sleeve gastrectomy, LRYGBP and gastric banding) which it contends are appropriate to address the patients presurgical history and potential postoperative concerns. However, no single alternative recommended by the Health Plan offers all of the advantages of the duodenal switch procedure. Furthermore, there is no compelling evidence that duodenal switch results in significant perioperative risks or postoperative nutritional complications. All told, the duodenal switch procedure is medically appropriate and necessary for treatment of this patients obesity.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested genetic testing for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested services in this clinical setting.  The panel that was ordered includes evaluation of conditions associated with aortic pathology.  The patient has a documented normal aorta by echocardiogram.  In the absence of aortic or other vascular abnormality, gene testing for conditions associated with aortic dilation, aneurysm and dissection is not indicated.  Based on the submitted medical records, the superior efficacy of the requested genetic testing has not been established.   Final Result: Two reviewers determined that the requested services are 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: One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. One reviewer is board certified in pediatrics and is actively practicing. One reviewer is board certified in pediatrics and clinical genetics and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for a transthoracic echocardiogram. Based on the records provided for review, this patient has a dilated non-ischemic cardiomyopathy with an initial recent left ventricle ejection fraction (LVEF). The patient did not subsequently demonstrate any symptoms or physical examination findings of heart failure while on low dose medication at follow-up visits with his provider. In this specific circumstance, additional therapies such as primary prevention defibrillator or biventricular pacing have not been shown to improve outcome and maximizing medication dosage is indicated regardless of findings on a follow-up echocardiogram. The records report clinical stability and use of low dose medication without documentation of maximization of medication prior to reevaluation. Therefore, the transthoracic echocardiogram was not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 certification in cardiovascular disease 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.