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

A 31-year-old male enrollee has requested Kenalog injections for treatment of his alopecia areata. Findings:  The physician reviewer found that alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss (Papadopoulos and colleagues). Although alopecia areata is not life threatening or painful, the onset and erratic nature disturbs the lives of many. Alopecia areata causes dramatic and devastating emotions in patients, which can negatively impact their self-esteem, body image, and/or self-confidence. The experience of alopecia is psychologically harmful and can result in emotional agony, producing personal and social problems (Tucker). Current research implicates T lymphocytes in the pathogenetic mechanism of this disease. Treatment is challenging and aims at the re-growth (reconstruction) of hair in affected individuals. Treatment of alopecia areata with intra-lesional steroid injection is generally recommended for people who have less than 50% scalp involvement. The goal is to achieve reconstruction (re-growth) of lost normal hair, rather than to change a pre-existing cosmetic defect. Given that alopecia areata is an immunological disorder, and in light of its detrimental psychological effects, the proposed injections are necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy. Researchers stated that `[c]hildren with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words.` Researchers review the importance of early intervention (less than 3 years) for children with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. Researchers concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal individuals with developmental disabilities. Researchers describe that treatment of individuals with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies.In this case, there was positive change between the skill level of the enrollee on the speech and language evaluation performed initially and that performed subsequently. The letter by the speech therapist who had been treating the enrollee clearly indicates that the enrollee is making progress with, and benefitting from, individual speech therapy. The requested authorization and coverage for speech therapy is therefore medically necessary for treatment of the enrollees medical condition (autism spectrum disorder).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 board certified neurologist with a special qualification in child neurology. 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 24 weeks for treatment of his chronic hepatitis C virus genotype 1b.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. For ribavirin ineligible treatment naive patients with decompensated cirrhosis and genotype 1 hepatitis C, the guidelines recommend Sovaldi with Daklinza for 12 weeks. The only Harvoni regimen recommended in decompensated genotype 1 patients requires the use of ribavirin. Although treatment of this patient is important and high priority, the AASLD/IDSA guidelines do not support the requested Harvoni for 24 weeks as medically necessary for treatment of this patients hepatitis C virus. 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 sub-specialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested continued physical therapy and rehabilitation in the skilled nursing facility for treatment of her status post hemorrhagic cerebrovascular accident.  Findings:  The physician reviewer found that this patient has a high baseline level of function, including living independently in the community, ambulating without an assistive device, driving and working.  She had profound acute changes to her functional status due to a hemorrhagic stroke.  She has been making slow, but fairly steady, progress while at the skilled nursing facility.  The distances she is ambulating and the level of assistance needed for ambulation have been improving steadily.  Her ability to transfer and perform self-care has been improving. This patient would have been expected to make further functional progress from the said date forward based on her progress up to that date and her high baseline functional status.  Stroke is a condition that is amenable to natural recovery and therapy interventions.  These expected functional gains would be clinically meaningful.  While these gains would not likely eliminate the need for care, they would be expected to significantly improve the patients independence. All told, continued physical therapy and rehabilitation in the skilled nursing facility during this timeframe was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for evaluation as the enrollee has a personal history of thyroid cancer. Findings:  The physician reviewer found that breast MRI has become increasingly useful in the work-up of many equivocal findings seen with conventional mammographic and ultrasound examinations of the breast.  However, as discussed by the American College of Radiology (ACR) practice guidelines, the presence of microcalcifications is not one of the indications for breast MRI. The negative predictive value for MRI is not sufficient to rule out ductal carcinoma in situ (DCIS). In this patients radiology report, the interpreting provider commented on the limitation of MRI in this particular set of circumstances. Overall, when calcifications are considered suspicious, MRI should not be used in lieu of the more invasive and revealing sampling by biopsy. For these reasons, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Helios braces for treatment of her peripheral neuropathy.   Findings:  Two physician reviewers found that the comprehensive rehabilitation of patients with Charcot-Marie-Tooth disease includes the use of properly fitted ankle foot orthosis (AFO) devices. These devices can reduce stumbling, tripping, or falling due to weakness and sensory deficits distal to the knee joint. In addition, properly fitted AFO devices may significantly reduce the need for proximal compensations and can improve lower extremity control during ambulation. Dynamic AFO devices also help reduce the energy expenditure of ambulation in patients with Charcot-Marie-Tooth disease (McCorquodale, et al). Further, in hemiparetic patients, dynamic AFO devices help compensate for foot drop as analyzed muscle activity was closer to a normal gait pattern when the dynamic AFO devices were worn (Zollo, et al). The records indicate that this patient experiences functional deficits secondary to bilateral foot drop. Her provider recommended Helios custom AFO devices to appropriately fit her individual needs for comprehensive disease management and rehabilitation goals. The Helios dynamic carbon-fiber AFO devices recommended are likely to provide this patient with a superior health outcome when compared to standard available alternatives and should therefore be approved.  Final Result: Two reviewers determined that the requested equipment is 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: All three reviewers are board certified in physical medicine and rehabilitation and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested coverage for third Hyaluronan injections for treatment of her bilateral knee osteoarthritis.  Findings:  Two physician reviewers found that the patient has bilateral osteoarthritis of the knees. The provider noted that the patient was not able to take anti-inflammatory medications due to reflux and dyspepsia, for which she was on Protonix. The patient wrote in her appeal letter dated that she had tried alternative treatments such as Tylenol, cortisone injections, physical therapy and weight control, yet her knee function was still compromised. The Health Plan has denied the patients request for a third series of Orthovisc injections for her bilateral knees as investigational. Although routine use of repeated series of viscosupplementation is not supported in the peer-reviewed medical literature, its use may be reasonable in this clinical setting. There are some data demonstrating the efficacy of a repeat series of injections. One systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee concluded that repeat courses of the hyaluronans are safe and effective in the treatment of pain associated with osteoarthritis of the knee (Pagnano and Westrich). Another study reported that repeated cycles of intra-articular sodium hyaluronate treatment was efficacious during a 54-month follow-up period in continuing to delay time to total knee replacement in patients with knee osteoarthritis (Turajane, et al). In addition, Raynauld and colleagues randomized controlled trial on effectiveness and safety of repeat courses of hylan G-F 20 in patients with knee osteoarthritis provided support for repeat treatments. One author cautioned that repeated viscosupplementation is not a cure for arthritis, but only provides comfort and functional improvement to temporarily avoid knee replacement (Spitzer, et al). Considering the alternative of invasive total knee replacement, this patient may receive benefit with a repeat a series of Orthovisc injections. While it is hard to predict which patients will respond based upon imaging or clinical indicators, those who experienced relief, and then recurred more than six months later, are likely to do well again. All told, the requested Orthovisc injections are likely to be more beneficial than any available standard therapy in managing this patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female has requested coverage for past as well as future skilled nursing facility services for treatment of her medical condition status post fistula repair.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue in this patients case.  As of a date at issue, the patient was stable on her medical therapy, was tolerating an oral diet, and had no complex wound care issues.  Per the therapy notes, she required minimal assistance with her activities of daily living.  She was receiving no intravenous medications, and she did not require further diagnostic studies or therapeutic interventions.  The submitted documentation does not demonstrate that the patient was expected to make any further measurable gains in a predictable period of time with continued skilled level of care services.  She did not require daily skilled therapy services to prevent deterioration with mobility or activities of daily living.  All told, skilled nursing facility services through the dates at issue, and continued skilled nursing facility services were not and are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old female patient has requested coverage for breast implant surgery. The patient has Poland syndrome, which has resulted in the underdevelopment of the right breast. A plastic surgeon evaluated the patient in December 2004 and noted the patient has severe breast asymmetry. The plastic surgeon has recommended the patient undergo bilateral breast augmentation and bilateral breast mastopexy for breast reconstruction. The Health Plan has denied authorization for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition. Review of the submitted clinical evidence reveals the patient has an incomplete variant of Poland syndrome with marked breast asymmetry. The issue at hand relates to what mode of surgical intervention to pursue. There have been varying opinions given by the consulting surgeons regarding the appropriate surgical intervention. It is doubtful the patients scoliosis and musculoskeletal complaints are related to breast asymmetry. The patient consulted a plastic surgeon who recommended bilateral breast augmentation and bilateral breast mastopexy for breast reconstruction. It appears the patient will benefit from reconstruction of the abnormal right breast via techniques described in the literature for treatment of Poland syndrome, together with left breast reconstruction to allow for symmetry. This is an acceptable, evidence-based approach. Unilateral (left) breast reduction may have significant psychological repercussions for the patient. Bilateral breast augmentation and mastopexy for breast reconstruction is more appropriate and should be authorized. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neutron beam radiation therapy for treatment of the enrollees recurrent adenoid cystic carcinoma in the mediastinum. Findings:  The physician reviewer found that there is a paucity of medical literature to support treatment with neutron radiation therapy for recurrent cancer. As noted by the National Comprehensive Cancer Network (NCCN), the data does not demonstrate that neutron radiation offers a clinical benefit compared to conventional radiation therapy techniques for adenoid cystic carcinoma. Further, neutron therapy is known to increase late complication rates compared to standard treatment with photon therapy. There are multiple studies which demonstrate that photon therapy can be safely administered to the mediastinum with acceptable risks of local control and toxicities. Based on these reasons, the requested neutron radiation therapy is not medically necessary for treatment of this patients adenoid cystic carcinoma of the lung. 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 radiation 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Moreover, there is sufficient support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, such as in this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 physician reviewers are 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: Overturned

The parent of a three-year-old male enrollee has requested speech therapy services, at a frequency of one time per week for one hour, occupational therapy services, at a frequency of one time per week for one hour, and physical therapy services, at a frequency of one time per week for one hour for treatment of the enrollees lissencephaly, global developmental delay, seizure disorder, esotropia and cortical visual impairment.  Findings:  The physician reviewer found that speech therapy services, at a frequency of one time per week for one hour, are medically necessary for the treatment of this patient.  He has significant neurological abnormalities, including lissencephaly, seizure disorder, cortical visual impairment, and sensorineural hearing loss, resulting in delay in acquisition of appropriate communication skills. Communication skills are essential to help this patient express his needs. The medical evidence supports speech therapy services in this clinical situation.  Occupational therapy services, at a frequency of one time per week for one hour, are medically necessary in this patients case.  He has delays in fine motor skills, self-help skills, and feeding skills. Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. In addition, with its focus on developing self-help skills, including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patient.  Physical therapy services, at a frequency of one time per week for one hour, are medically indicated for the treatment of this patient.  As a result of structural abnormalities (rocker bottom feet) and global hypotonia, this patient has significant gross motor deficits impacting acquisition of stationary and locomotion skills.  Physical therapy is ideally suited to optimize this patients gross motor skills, including balance, standing, strength, and ambulation. All told, the requested services are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. This patient presents with chronic back pain that has not substantially improved despite conservative treatment. The patients provider has recommended treatment with the Intracept procedure. The peer-reviewed medical literature has demonstrated that the Intracept procedure can provide long-term improvement of chronic low back pain in patients who fail to improve with conservative care. The current treatment modalities for this patient population includes fusion or artificial disc replacement. The Intracept procedure offers a less invasive outpatient procedure that maintains the structural integrity of the spine. Patients have been shown to have significant improvements in pain and overall return back to high functioning level with the Intracept procedure (Truumees, et al.; Khalil, et al; Markman, et al.). All told, the requested Intracept procedure is 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 requested Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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.