Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Flexitouch pneumatic compression device.Findings:  Two of the three physician reviewers found that the Flexitouch pneumatic compression device is indicated for the treatment of lymphedema, primary lymphedema, post-mastectomy edema, edema following trauma and sports injuries, post-immobilization edema, venous insufficiencies, treatment and assistance in healing stasis dermatitis, venous insufficiency ulcers, or arterial and diabetic leg ulcers. Studies have shown that compression devices can reduce lymphedema effectively. These types of devices can be recommended for short-term use in combination with a lymphedema treatment program for reducing cancer-related lymphedema. In this patients case, cancer-related edema is present despite treatment with a standard lymphedema program and other interventions. Therefore, the Flexitouch pneumatic compression device is likely to be superior over other treatment options.Final Result: Two of the three reviewers determined that the requested device 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:  One reviewer is board certified in internal medicine and is actively practicing. One reviewer is board certified in internal medicine and is actively practicing. One reviewer is board certified in internal medicine, with subspecialty certificates in hematology and medical oncology, 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for ovarian vein and possible iliac vein branch embolization. Treatment options for pelvic congestion syndrome are limited, but data support favorable outcomes with specific interventions. Medical literature provided data demonstrating that ovarian vein and possible iliac vein branch embolization are safe and effective in well-selected patients. The available data suggests that although hysterectomy is one treatment modality for pelvic congestion syndrome, it may not be the most effective option. This patient continues to have pain one year after her procedure and has worsening radiological findings consistent with pelvic congestion syndrome. Therefore, the requested ovarian vein and possible iliac vein branch embolization 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 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: Medical Necessity
Decision: Upheld

A female enrollee requested bilateral hip and back panniculectomy and bilateral medial thigh lift for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records and photographs do not demonstrate that a significant functional deficit is present to warrant surgical intervention.  All told, the requested bilateral hip and back panniculectomy and bilateral medial thigh lift are not medically indicated for the treatment of this patient and are not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested a breast MRI for evaluation of her medical condition.  Findings:  The physician reviewer found that there are several indications for MRI of the breast which include evaluation of pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High-risk patients also include patients with biopsy proven atypia, lobular carcinoma in situ, radial scar and prior mantle radiation. This patient has two of the above-mentioned indications for a breast MRI.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 29-year-old G4P1Ab3 female who has a history of two spontaneous abortions followed by a successful term pregnancy, then another spontaneous abortion. She was found to have a borderline lupus anticoagulant antibody level at the time of her third pregnancy and was treated with Lovenox and aspirin. The patient was diagnosed as having antiphospholipid syndrome and after her third miscarriage, she was advised to have treatment with intravenous immunoglobulin (IVIG). The record provided for review reveals a single, borderline lupus anticoagulant level with two subsequent negative levels in July and August 2005. Screening for anticardiolipin antibodies was negative and the natural killer (NK) cell assay performed in July 2005 was within the normal laboratory reference ranges. The patient would like to become pregnant again, and her provider has recommended treatment with IVIG to decrease the risk of pregnancy loss. The Health Plan denied the patients request for authorization based upon a determination that IVIG therapy is not medically necessary.The record indicates a diagnosis of antiphospholipid syndrome and elevated NK cells. However, the NK cell levels were within normal limits and the lupus anticoagulant level was borderline high and the elevation did not persist. ACOG Practice Bulletin #68, which addresses antiphospholipid syndrome, states there must be a positive test on two or more occasions at least six weeks apart. As such, the diagnosis of antiphospholipid syndrome is suspect and is not supported by the records provided for review. Practice bulletin #68 also states that a recent small, randomized, controlled study demonstrated no greater benefit from IVIG (plus heparin and aspirin) than with heparin and aspirin alone. Because the efficacy of IVIG has not been proven in appropriately designed studies and the drug is extremely expensive, it is not recommended as primary therapy.  Therefore, even with a confirmed diagnosis of antiphospholipid syndrome, the current evidence would support treatment with aspirin and heparin, not with IVIG therapy.  Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment, wilderness therapy. Recent progress notes indicate the patients primary issues are mood related. His recent depression rating scale was in the moderate range. Recently, he has been intermittently compliant with his medications. He appears to be overall cooperative with treatment and is open and responsive to his current providers. The progress notes do not document any suicidal or homicidal thoughts. His activities of daily living appear intact as referenced by his attendance to his appointments and school. He does not appear to be experiencing any psychosis. He reports daily cannabis use and there is no indication he has any serious acute medical problems. Recent progress notes indicate a clinical recommendation for weekly therapy. The patients family has been involved in his treatment. Applying the Level of Care Utilization System (LOCUS), this patient does not meet the criteria for residential treatment, wilderness therapy services. The patient is currently at minimal risk of harm (score 1) due to a lack of current active or passive suicidal ideation. The patient has moderate impairment in his ability to function (score 3) as demonstrated by his inability to fulfill some responsibilities and interpersonal issues. The patient presents with minor medical, addictive and psychiatric co-morbidity (score 2) due to current cannabis use and no medical issues. The patients recovery environment is mildly stressful (score 2) due to some minor relational issues with family. His recovery environment is supportive (score 2) as he has access to supportive resources who are willing to provide aid. Further, the patient has demonstrated limited response to prior treatment (score 3) due to some treatment response in the past, but continued symptoms and occasional refusal to take medications. The patient has been cooperative in treatment but lacks insight into the need for treatment (score 3). This gives the patients presentation a composite score of 16.  A score of between 17-19 correlates with a treatment intensity level of two, which is described as low intensity community based services. According to the patients score on the LOCUS, residential treatment, wilderness therapy, is not medically necessary. 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 psychiatry with subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan. Based on the review of the records and evidence based research regarding use of SPECT scan for the patients condition, the SPECT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. It has been shown that SPECT imaging studies demonstrate selected areas that are affected by multiple drugs among substance abusers and can be useful to confirm specific diseases and clarify diagnosis wherein the clinical picture is not observed. However, in this case, there is no additional benefit for the SPECT scan as it was not expected to change the diagnosis or treatment plan. The use of SPECT scanning had no additional benefits compared to other available standard therapies available for this patients depression or substance use. Thus, the SPECT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the SPECT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the SPECT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested lab testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the lab test was not likely to be more effective for this patient than other available options. Per the American Joint Committee on Cancer (AJCC), the presence of circulating tumor cells in the blood does not define metastasis. For metastatic disease, the enumeration of circulating tumor cells at the time of diagnosis of metastasis has been shown to strongly correlate with survival, but neither the presence nor the number of circulating tumor cells will change classification.  Researchers showed that for patients with persistent elevation of circulating tumor cells after 21 days of chemotherapy, early switching to an alternative regimen did not prolong survival. Thus, the lab testing at issue was not 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 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested Avastin (J9035) for treatment of her metastatic leiomyosarcoma with metastatic involvement of the lungs.  Findings:  Three physician reviewers found that Avastin is a monoclonal antibody targeting the vascular epithelial growth factor.  It has been approved for use in multiple cancers, particularly when combined with chemotherapy. The extent of the data regarding its use in soft tissue sarcomas is limited. In the study by DAdamo and colleagues, 17 patients with soft tissue sarcoma were treated with Avastin combined with doxorubicin.  Although there were a few responses, there was significant toxicity.  Accordingly, it was recommended that this approach not be further pursued.  There is a lack of data supporting the use of Avastin in this clinical scenario.  The current medical evidence has not demonstrated the benefit of the use of Avastin for patients with soft tissue sarcomas.  All told, Avastin is not likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 19-year-old recurrently ill anorexic female with prior residential and outpatient treatment for her severe anorexia nervosa, with classic restricting, purging and excessive exercise. She entered acute inpatient care in January 2006, remaining until transition to residential care in March 2006. Her care was covered by the Health Plan until February 2006. At issue is whether acute inpatient services were medically necessary as of February 2006.A review of this lengthy file reveals a patient who was a very ill, depressed and obsessed anorexic patient. She did manage to cooperate and gain weight during her initial stay but was still capable of significant relapse as of February 2006. As such, she was not yet ready to leave acute inpatient care. She required extensive supervision and structured treatment management of all of her behavior and eating, if she was to improve.The submitted documentation does not demonstrate that the patient stable and ready for transfer as of February 2006. She remained manipulative around food and needed additional motivation to improve while being intensely monitored. Therefore, I have determined the services at issue were 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: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of spinal canal (CPT 72141). The records document that this patient presents with neck and upper back pain. The patient was noted to have sustained an injury about seven years prior that was managed with physical therapy and acupuncture without lingering pain. The records do not document any recent history of trauma, neurologic impairment, or suspicion of severe illness such as malignancy. In this clinical setting, specifically advanced imaging such as MRI is not recommended by the medical literature (Cohen; Nakashima, et al.). Initial treatment should include an anti-inflammatory medication such as naproxen and physical therapy. MRI is not recommended during the initial evaluation stage. Based on current data, a cervical spinal MRI is not indicated for this patient with neck pain without neurologic impairment or historical or examination findings suggestive of serious pathology such as myelopathy, atlantoaxial subluxation, or metastases. All told, the requested MRI of spinal canal (CPT 72141) is not medically necessary for this patient. 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 orthopedic surgery with subspecialty certification in sports 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

The patient has requested authorization and coverage for a spinal cord stimulator. Researchers evaluated the benefits of high frequency spinal cord stimulation for surgery naive patients with low back pain. The authors reported that their results showed a 50% improvement of low back pain with a mean follow-up of 306 days after implantation. They also concluded that, the option of spinal cord stimulation should be considered after conservative therapy has failed. In this case, the patient has diffuse low back pain with radiation into the right anterolateral thigh and right groin along with a history of multiple falls. The patients chronic pain involves the neck, shoulders, fingers, calves and feet. She has magnetic resonance imaging (MRI) results confirming degenerative changes at L3-4 and L4-5 with foraminal narrowing. She also has a history that is notable for fibromyalgia and bipolar disorder. She has tried and failed multiple medications and interventional therapies such as sacroiliac joint injections, lumbar facet injection, radiofrequency ablation, and epidural steroid injections. The records do not include a pain psychology evaluation to determine if she is an appropriate candidate for spinal cord stimulation. The patient has complaints involving several areas beyond the low back that would not be treated by the spinal cord stimulator. Further, the patients fibromyalgia and bipolar disorder are contraindications to a spinal cord stimulator, as they affect the expectations of pain relief and perception of benefit from the stimulator. Given these findings, the requested spinal cord stimulator is not medically necessary for treatment of this patient. 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 anesthesiology with subspecialty certification in pain management 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: The parent of an enrollee has requested authorization and coverage for somatropin 1.5 mg. Based on the policy criteria, the GH is not medically necessary for a diagnosis of GH deficiency because the patient passed the GH stimulation test and had a peak of GH of greater than 10 ng/mL. However, the patient meets the criteria for GH therapy based on the criteria for GH treatment that require given his short stature is below standard deviations below the mean. Moreover, the patients condition is consistent with idiopathic short stature, which is known to be responsive to GH therapy and it is very likely he has some underlying genetic defect given the extreme short stature of his mother. In addition, based on practice clinical guidelines by the Pediatric Endocrine Society and based on U.S. Food and Drug Administration (FDA) approval for GH for extreme short stature this patient qualifies for GH treatment. Thus, the requested somatropin 1.5 mg is supported as medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 57-year-old male enrollee has requested for Gleevec (imatinib) for treatment of his Acute Myeloid Leukemia (AML). Findings:  The physician reviewer found that there is very little data regarding the use of Gleevec in AML, even those with c-kit mutation. There have only been small studies published over the past few years that do indicate some degree of activity in this situation (see Kindler, et al.). However, Chevallier, et al. published a particularly negative trial. Therefore, there is no convincing evidence that there is a sufficient likelihood of benefit from Gleevec for this patient when used as a maintenance therapy.