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

The patient is a 12-year-old male with a diagnosis of Aspergers Syndrome and a co-morbid diagnosis of ADHD. Several medications have been tried such as Ritalin, Concerta, Adderall and Adderall XR. 40mg of Focalin XR daily was clinically effective in treating the patient. The FDA recommends a maximum dosage for Focalin XR of 20mg daily. The patients parent submitted a request for reimbursement and prospective authorization of Focalin, 40mg daily. The Health Plan denied the request based upon a determination that the medication dosage was/is not medically necessary.The literature does recognize the use of Focalin in dosages as high as 40mg per day for certain individuals who have ADHD and have not responded to lower dosages of stimulants. Focalin is a potent stimulant, and there are some potential health concerns with prescribing this medication at a higher dose. A cardiac assessment should be carried out to rule out any pre-existing cardiac abnormalities. This may be accomplished through the patients primary care provider in conjunction with a complete physical examination. Periodic monitoring of the patients physical health status is also recommended. Focalin XR, 40mg daily, has been shown to be effective for this patient. Assuming there are no medical contraindications for the use of Focalin XR at this dosage, the clinical indications support the use of Focalin at the prescribed dosage. Objective measures of on-going efficacy such as the Conner Teacher rating scale are generally helpful in this context. In summary, although the prescribed Focalin XR dosage of 40mg daily exceeds the FDA recommendation, the literature does support this dosage for selective patients with ADHD. As there are potential side effects of a cardiac nature, if the patients cardiac status has not been recently evaluated, such evaluation should occur as soon as possible. Therefore, I have determined the medication at issue was/is medically necessary for treatment of the patients medical condition pending cardiac evaluation. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Otoscope Panel Genetics testing for evaluation of the enrollees prelingual hearing loss. Findings: Three physician reviewers found that Otoscope Panel Genetics testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Shearer and Smith performed a literature review to evaluate the use of new genetic sequencing techniques for comprehensive genetic testing for hearing loss. An analysis of 20 studies of next generation sequencing in patients with hearing loss found that the overall diagnostic rate was 41%. Some studies had diagnostic rates as high as 83%. The study suggested that comprehensive genetic testing has become the new standard of care for genetic testing for patients with sensorineural hearing loss. Moreover, identifying a specific cause of hearing loss can allow for prediction of associated complications and direct care. This patient likely has a syndromic cause for his hearing loss given the ear malformations. Accordingly, genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested testing is 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 board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orap 1 mg, once daily for treatment delusions of parasitosis and prurigo nodularis. Findings:  The physician reviewer found that treatment with Orap is well established in the medical literature for treatment in this clinical setting. Orap is the standard of care first-line treatment for delusions of parasitosis. The patient tried treatment with generic pimozide and had poor control of symptoms and side effects. Thus, the continued use of Orap is clinically indicated for this patient to control disease and improve function. 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 physician 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for the gene panel testing. Findings:  Two of the three physician reviewers found the submitted documentation supports a portion of the services at issue. The noninvasive prenatal testing was performed because the patient will be greater than 35 years of age at the time of delivery. The American College of Obstetricians and Gynecologists endorses the use of noninvasive prenatal testing in this high-risk patient population. Advanced maternal age is a risk factor for aneuploidy. Per the medical evidence, aneuploidy screening was likely to have been more efficacious than other available modalities for evaluating this patient. However, given that the records do not document sex-linked specific risk factors, fetal sex determination was not indicated. All told, a portion of the services at issue was likely to have been more beneficial than other modalities for evaluating this patient. Specifically, all tests of the performed gene panel testing, except fetal sex determination, were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that Botox is medically indicated for blepharospasm and symptomatic torsion dystonia. This patient suffers from both of these conditions and has experienced relief from prior use of Botox. There is medical literature supporting the use of Botox for these conditions as referenced.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that The use of a repeat MRI after a patients confirmed biopsy without concomitant plans for rebiopsy, such as with MRI guided or ultrasound fused biopsy, is not supported per the American Urological Association (AUA) or National Comprehensive Cancer Network (NCCN) guidelines. Review of the records indicates that this patient is at moderately low risk category for advancing prostate cancer. In this patients case, the Health Plan has denied an MRI since it was requested without an associated biopsy, which would be appropriate. A multiparametric MRI will have the highest sensitivity in evaluating the prostate capsule and extraglandular disease. Coupling the multiparametric MRI study with the ability to perform a biopsy during the examination would be reasonable given this patients clinical history. Thus, the requested MRI is not supported as medically necessary for evaluation and treatment of this patients prostate cancer. Final Result: The reviewer determined that the requested services are 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 radiology 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 reimbursement for inpatient liver ablation treatment stay for treatment of the enrollees liver cancer. Findings:  The physician reviewer found that Large clinical trials of radiofrequency ablation of hepatocellular carcinoma have included inpatient admission as standard of care.  Patients with cirrhosis have almost twice the rate of early complications, some fatal, after this procedure.  These include pneumonia, sepsis, liver failure, bleeding, and bile leak, all of which can be diagnosed and addressed in an inpatient setting.  Some of these complications, such as retroperitoneal bleeding, can manifest hours after the procedure or the next day.  Additionally, when lesions are near the liver capsule as in this case, there is an increased risk for injury to adjacent organs during the procedure. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a mandibular advancement device for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. This patient does not have clinically significant obstructive sleep apnea, and there is no indication for treatment of obstructive sleep apnea.  The usual criteria to treat obstructive sleep apnea in the absence of hypertension, cerebrovascular accident or heart disease, is an AHI of 15 or higher.  The patient does not meet this criteria.  All told, the requested mandibular advancement device is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 pulmonary 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female with markedly short stature. She has been on growth hormone therapy since the age of 13. According to her physicians note of November 2003, the patient was 39.25 inches and had a bone age of 11 years. Her predicted adult height at that time was estimated at 54.1 inches. She had received Ritalin and Strattera in the past. Her endocrine workup excluded GH deficiency and primary ovarian failure of Turners syndrome. She was noted as having a goiter, but thyroid function tests results have not been provided. Growth hormone therapy was subsequently initiated at the age of 13. In March 2006 the patients height was noted as 55.75 inches, indicating a positive response to GH therapy. At issue is whether growth hormone therapy is medically necessary for treatment of the patients condition.The Food and Drug Administration has approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. The submitted clinical information indicates the patient has had a significant growth response since GH therapy was initiated. While the patients presentation is consistent with idiopathic short stature, thyroid functions tests have not been provided to rule out other possible causes for her delayed growth. Therefore, I have determined that GH therapy is medically necessary depending upon the results of thyroid function testing. The Health Plans denial should be overturned. If there is evidence the patients thyroid function is normal, GH therapy should be authorized/covered. If there is not evidence the patients thyroid function is normal, the GH therapy should not be authorized/covered.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old female enrollee has requested  sensory integration based occupational therapy and/or sensory integration based speech therapy for the treatment of the enrollees sensory processing and integration difficulties. Findings:  Two physician reviewers found that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. The therapy at issue was and is medically indicated to allow this patient to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that there is medical justification for viscosupplementation treatment and even one-time re-treatment when specific criteria are met. However, there is insufficient evidence to show long-term benefit of multiple re-treatments with viscosupplementation injections of the knee. The benefit of more than two series of viscosupplementation injections has not been established in the scientific literature. In addition, multiple repeat series of viscosupplementation injections is not U.S. Food and Drug Administration (FDA) approved and is not considered medically necessary by Centers for Medicare and Medicaid Services (CMS). 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 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 male enrollee has requested repair of anorectal fistula (with plug) for treatment of his anal fissure.  Findings:  Three physician reviewers found that in this patients case, the services at issue were likely to have been more efficacious than other treatment options.  Based on the current literature, the use of bioprosthetic anal plugs may be indicated in cases of complex fistulas.   The literature indicates that they may promote healing and perianal hygiene and improve quality of life.  The submitted medical records indicate an extensive complex fistula.  There is sufficient support for the services at issue in this clinical setting.  All told, repair of anorectal fistula (with plug) performed on the date indicated was likely to have been more effective than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage of digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis was was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was 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 board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for breast cancer.Findings:  Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone.Final Result: Two reviewers determined that the service at issue was 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 board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested repeat right knee viscosupplementation with Orthovisc for treatment of his degenerative joint disease of the right knee. Findings:  Two physician reviewers found that this patient had an excellent response in the past to the series of Orthovisc injections.  He has an accelerated degenerative osteoarthritis.  Per the medical literature, hyaluronic acid injections are indicated for moderate to severe osteoarthritis and are indicated for treatment about once a year to help delay surgery or to supplement for surgery in patients who are not surgical candidates.  In this case, the submitted documentation does not note any contraindication for repeat viscosupplementation therapy with Orthovisc, and the results he has had thus far have been excellent. A literature review shows the benefit of repeat right knee viscosupplementation in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested custom orthotic shoe inserts for treatment of her high arches and arch strain.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested custom orthotic shoe inserts. The medical literature concluded the prescription of custom foot orthotics has gold-level evidence for painful pes cavus. Moreover, the medical literature concluded that custom made foot orthoses are significantly more beneficial than sham orthoses for treating foot pain associated with pes cavus. Custom made foot orthotics are generally utilized to treat painful foot deformity and the medical literature supports this practice. As such, the requested custom orthotic shoe inserts are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.