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

An enrollee has requested authorization and coverage for Xtandi (enzalutamide) 160 mg daily. The medical literature supports that the requested medication is medically necessary. The androgen receptor (AR) is expressed in both normal and malignant breast tissue. While luminal, hormone receptor-positive breast cancers more commonly express AR (91 percent), triple-negative breast cancer (TNBC) expresses AR approximately 30 percent of the time. The potent AR inhibitor enzalutamide (Xtandi) was evaluated among 118 patients with AR-positive metastatic TNBC (55 percent of 404 screened). Two complete responses and five partial responses were observed. Clinical benefit rate (CBR) at 16 weeks was 35 percent (95% confidence interval (CI) 24-46), and was 39 percent (95% CI 27-53) among those whose tumors expressed an AR-driven gene signature. In this case, the patient has limited treatment options, and given pathology results showing 100% of cells androgen positive, the patient is likely to have a good response to enzalutamide with limited toxicities. Under these circumstances, the requested medication Xtandi (enzalutamide) 160 mg daily is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in hematology and medical oncology, 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

The parent of a three-year-old male enrollee has requested dynamic posturography (vestibular research) for the treatment of the enrollees hearing loss, unsteadiness, imbalance and frequent falls. Findings: Two physician reviewers found that dynamic posturography is utilized in evaluating and defining different types of balance disorders. It may be useful in the study of patients who have otherwise normal results with standard tests such as videonystagmography, but who have problems with balance.  It may be used by physical therapists in assessing fall risk.  Most of the current literature indicates that dynamic posturography is used mainly as a research and laboratory tool.  This patient has balance problems. He also has a history of chronic middle ear disease and there is documentation in the provided records of a mild bilateral conductive hearing loss. A child with chronic recurrent ear infections may have balance difficulties based on obvious peripheral etiology. The addition of dynamic posturography to this patients evaluation was not likely to yield any additional clinically useful information.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested reduction mammoplasty surgery for the treatment of her neck, shoulder and upper back pain. Findings:  The physician reviewer found that although this patient appears to be an appropriate candidate for reduction mammoplasty, there is no evidence that she has been evaluated by a plastic surgeon. A plastic surgeon should evaluate this patient to determine if she is an appropriate candidate for breast reduction surgery. If the plastic surgeon determines the patient is an appropriate candidate for reduction mammoplasty, the surgery should be authorized. However, at this time, without a plastic surgery evaluation, it cannot be determined that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly speech therapy. Based on the available documentation, this patient with autism and Down syndrome has participated in speech therapy for several years with slow progress. In July 2020, the provider reported that the patient has met one of six goals, significant progress in two of six goals, and progress in the remaining three goals. According to the National Down Syndrome Society (NDSS), patients with Down syndrome frequently have difficulty with grammar, tenses and word endings and use shorter sentences to communicate. In the medical literature, researchers noted that language disorder is a cardinal challenge for children with Down syndrome and these patients have the potential to respond to language intervention. Another study noted that the achievement of speech intelligibility by patients with Down syndrome facilitates their participation in society. Given this patients slow progress with speech therapy thus far, continued weekly speech therapy is consistent with current medical literature recommendations. Therefore, the requested weekly speech therapy 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 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: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested reimbursement for the radiofrequency ablation. On review of the current medical literature, there are data to support the use of radiofrequency ablation in spine. However, there is a paucity of adequate evidence demonstrating improved patient health outcomes with radiofrequency ablation of the hip. Overall, the studies on radiofrequency ablation of the hip include retrospective, case series, and pilot studies. In addition, this patients records provided for review do not include provider documentation outlining the standard treatment options for pain have been exhausted. Specifically, treatment with behavior therapy has not been attempted, despite much research to support its use in this clinical setting. Moreover, not all antidepressants used for pain have been optimized or tried. Furthermore, the test block was performed with steroid without a pain diary. For these reasons, the radiofrequency ablation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the radiofrequency ablation was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing.  One Reviewer is board certified in anesthesiology with subspecialty certification in pain management 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cosentyx 150 mg/mL syringe, two applications subcutaneously once per week for five weeks, quantity 10, with six refills. Chronic plaque psoriasis is a disease that affects not only the skin but a patients quality of life. The U.S. Food and Drug Administration (FDA) approves the use of Cosentyx, a human interleukin-17A antagonist, for the treatment of moderate-to-severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy, adults with active psoriatic arthritis, and adults with active ankylosing spondylitis. Menter and colleagues note that Cosentyx is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. Langley and colleagues report that two phase III trials have established the efficacy of Cosentyx in patients with moderate-to-severe psoriasis, with the percentage of patients who achieved a reduction of 75% or more from baseline in the psoriasis area-and-severity index score (PASI75) at week 12 being higher with secukinumab dosage than with a placebo or with etanercept. In this clinical setting, current medical literature shows that Cosentyx is considered safe, effective and appropriate for the treatment of psoriasis. Therefore, Cosentyx 150 mg/mL syringe, two applications subcutaneously once per week for five weeks, quantity 10, with six refills 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 55-year-old female enrollee requested authorization and coverage of a CT scan of the chest for an evaluation of chest pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SpaceOAR System (CPT 55874). This patient has a history of stage T1 Gleason score 4+4=8 adenocarcinoma of the prostate. The patient underwent treatment with Lupron as well as prostate seed implantation along with external beam radiation therapy with placement of SpaceOAR perirectal spacers. One important consideration during prostate radiation is rectal toxicity due to exposure of the adjacent rectum to radiation. A mechanism of dealing with this issue is to create a space between the prostate and rectum, so that the rectum is out of the radiation treatment field and receives less radiation. Karsh and colleagues reported on a phase 3 study evaluating the safety and effectiveness of the SpaceOAR perirectal spacer in the treatment of prostate cancer. The authors found that the patients who underwent radiation therapy with SpaceOAR placement experienced reduced rectal radiation and rectal toxicity as well as improved bowel quality of life. The National Comprehensive Cancer Network (NCCN) recently endorsed the use of SpaceOAR perirectal spacers and noted that their use can improve sparing of the adjacent rectum in patients undergoing radiation therapy for prostate cancer. Based on the results of the positive phase 3 study and the endorsement by the NCCN, the placement of SpaceOAR System (CPT 55874) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Findings:  Three of the three physician reviewers found the placement of SpaceOAR System (CPT 55874) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The father of a 19-year-old female enrollee requested authorization and coverage for continued speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees delayed speech status post traumatic brain injury.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested a WalkAide neuromuscular electrical stimulator for the treatment of her cerebral aneurysm and lower extremity hemiplegia. Findings:  Three physician reviewers found that this patient has a brain injury secondary to hemorrhage with foot drop. She has tried the WalkAide NMES with improvement in her gait. This device is gaining widespread utilization and has been demonstrated to improve gait speed. Positive effects have been seen in appropriately selected patients. While an ankle foot orthosis (AFO) is often adequate for some patients, this patient is young and normalization of gait will prevent further issues in the future. There are several small studies that demonstrate a positive effect on gait. Although further study of the WalkAide device is needed, there is adequate evidence at this time to conclude that the device is likely to be of greater benefit for this patient than standard therapy. The recent studies support the beneficial effects this device has on gait and balance in similar patients.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested inpatient psychiatric hospitalization services for medical treatment of her bipolar disorder, depression, and anxiety.  Findings:  The physician reviewer found that the medical records demonstrate that inpatient psychiatric hospitalization services were medically necessary for treatment of this patients medical condition.  At admission, the patient continued to state that she was very depressed and reported suicidal ideation. Given the patients research for weeks and suicide attempt in the few days prior to admission, and her history of impulsivity, continued observation for her safety was clinically appropriate. Applying the American Psychiatric Association (APA) guidelines, hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patient was severely depressed with suicidal ideation throughout her admission. All told, acute inpatient hospitalization was appropriate to treat the patients condition, which could not have been provided safely in a less restrictive treatment setting, and it was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The patient with bulima nervosa, depression and anxiety requested Intensive Outpatient Program Services. The medical literature indicated that continued intensive outpatient program stay is generally needed until IOP is no longer necessary due to adequate patient stabilization improvement as indicated by weight stable, increasing or any issues manageable at a lower level care; purging and other behavior is manageable at a lower level of care; the status acceptable; medical needs absent or manageable at a lower level care. This patient had tried and failed treatment before.  Increasing weight, purging and other behaviors were not manageable at a lower level of care.Final Result: The reviewer determined that the service at issue was medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and is actively practicing.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for rhinoplasty which includes septoplasty procedures (CPT 30420 and CPT 30520).Rhinoplasty is a surgical procedure to smooth out the nasal deformities and to fix nasal breathing problems. Improving nasal valve angle has been shown to improve nasal breathing. In this case, the patient was involved in a motor vehicle accident that resulted in suffering nasal obstruction. The submitted records document that the patient has a septal deviation, and the submitted photographs of the patient demonstrate valve collapse with inspiration. The submitted records reflect that a Cottle maneuver improved the patients nasal breathing, thereby indicating nasal valve collapse. Under these circumstances, a septoplasty will be necessary to correct the septal deviation that was also caused by the accident. Accordingly, the requested rhinoplasty which includes septoplasty procedures (CPT 30420 and CPT 30520) is medically necessary for the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient requires surgery to correct or repair nasal obstruction and septal deviation, which are trauma that were caused in this instance by a motor vehicle accident. The requested surgery will improve the patients nasal breathing, thereby improving function. The submitted photographs of the patient also demonstrate valve collapse with inspiration, and the requested surgery will thereby provide more than a minimal improvement in the appearance of the patient. Therefore, the requested rhinoplasty which includes septoplasty procedures (CPT 30420 and CPT 30520) is reconstructive in nature for treatment of the patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for applied behavior analysis (ABA) services consisting of 78 hours per month of direct 1:1 therapy by a paraprofessional, eight hours per month of supervision, two hours per month of parent training, and five hours for reassessment. Based on the information reviewed, this patient meets the criteria for medical necessity for ABA services. The patients provider conducted the Vineland Adaptive Behavior Scales - 3 (Vineland-3), which measures areas related to autism spectrum symptoms, specifically, socialization, communication, daily living skills, and an adaptive composite. The patients scores reflected significant deficits in socialization and deficits in the adaptive composite score. Age equivalents in the area of socialization were also significantly discrepant from their chronological age in the areas of interpersonal relationships and play and leisure skills. The Vineland-3 is both a reliable and valid assessment measure to support ABA therapy for this patient. In addition, the patients provider included clearly defined and measurable goals for specifically targeted behaviors and skills directly related to autism. The patients treatment plan includes 12 goals, four problem behavior goals, and four parent training goals. Each of these goals is broken down into baseline, discriminative stimulus, goal, and current progress. Further, each goal identifies the specific areas that will be addressed including health and safety, adaptive functioning, social functioning, executive functioning, play and problem behavior. Moreover, ABA services are consistent with the recommendations from the Behavior Analyst Certification Board (BACB). The BACB highlights that the number, complexity, and intensity of behavioral targets and the clients own response to treatment define treatment intensity. Based on the number of goals identified, presenting behavior concerns, and progress made thus far, the request is well within the focused level of treatment requested for this patient. Therefore, the requested ABA services consisting of 78 hours per month of direct 1:1 therapy by a paraprofessional, eight hours per month of supervision, two hours per month of parent training, and five hours for reassessmenT 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 a licensed BCBA and is board certified in psychology 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 54-year-old male enrollee requested authorization and coverage of sixty-six single use urinary catheters a month for the treatment of urinary retention.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested equipment is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were likely to have been superior over other modalities.  The technique has been associated with a significant decrease in callbacks and increased detection of small cancers when employed as part of the usual screening.  This improvement is based upon the unique tomographic capability of tomosynthesis.  All told, breast tomosynthesis was likely to have been more beneficial to the patient than digital mammography alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three 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.