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

The parent of a one-year, three-month-old male enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that down syndrome is a chromosomal disorder characterized by hypotonia, dysmorphic features, and global developmental delay. This diagnosis requires intervention and continuous treatment from specialized providers. Occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for the patient with motor delays. These goals often involve social interaction, behavior, and classroom performance. To support the need for OT, studies have shown benefits that prevent a deterioration or reversal of function and a significant improvement in activities of daily living. Further, the peer reviewed medical literature suggests that the OT affected gross motor gains for preschool children who exhibited moderate motor delays. Specifically addressing the needs of young patients with Down syndrome, the results of the study by Uyanik and colleagues showed that sensory integration, vestibular stimulation and neurodevelopmental therapy were effective interventions. The authors concluded that when designing rehabilitation programs for children with Down syndrome, all treatment methods should be applied in combination, and should support each other according to the individual needs of the child. In a study of older children with Down syndrome the research indicated that a wide range of performance of self-care activities appeared most delayed on activities that required fine motor skills. As such, the requested OT is medically necessary and should be provided at least three hours per week by an occupational therapist. Additionally, the patients caregivers should be instructed on how to provide therapy at home.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a vertical sleeve gastrectomy for medical treatment of her status post laparoscopic removal of adjustable gastric band.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient does not meet the standard criteria for bariatric surgery. There is no basis or rationale for proceeding with pre-emptive bariatric surgery. In addition, there is no indication in the medical record that she is actively engaged in non-surgical weight loss program with the goal of avoiding weight gain following removal of the band. For the reasons provided, the requested procedure is not medically necessary for the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two reviewers found that 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 it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging especially in patients with dense tissue such as in this case. Thus, the addition of tomosynthesis 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: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested oral surgery and follow-up services for treatment of his class III malocclusion.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services.  This patient has been diagnosed with a maxillofacial skeletal deformity. This deformity cannot be corrected by non-surgical means, and the patient will require orthognathic surgery. As a result of the surgery, the patient is likely to have improved occlusion and improved musculoskeletal and dento-osseous relationships. Additionally, improved mastication and swallowing are likely to occur following surgery.  The American Association of Oral and Maxillofacial Surgeons and current literature support the requested services in this clinical situation.  All told, the requested oral surgery and follow-up services are medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee requested oxymorphone HCL 10mg tablets #90 for medical treatment of the enrollees back pain.  Findings:  The physician reviewer found that oxymorphone HCL is not medically necessary for treatment of the patients medical condition. Review of the documentation provided demonstrates the patient has a chronic pain condition secondary to lumbar degenerative disc disease. Additionally, the patient has a history of liver disease due to hepatitis C virus. As a result, the patient needs to avoid products containing acetaminophen, non-steroidals and most medications metabolized by the liver. The submitted records indicate that the patient cannot tolerate Butrans or Norco; however, there was no documentation of failure to other medications including oxycodone, morphine or methadone - all of which have a high safety profile in patients with liver failure and are FDA-approved in low doses for moderate to severe chronic pain, particularly due to spinal and joint pain. Given the availability of medically appropriate alternatives, oxymorphone HCL 10mg tablets #90 is not medically necessary for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for Hyalgan injections for treatment of her bilateral knee osteoarthritis.   Findings:  Three physician reviewers found that this patient has undergone intraarticular cortisone injections. These were helpful initially, but lost their effectiveness. The patient has also had Synvisc and Hyalgan injection series with a reaction to the Synvisc. There are no studies demonstrating the efficacy of repetitive use of viscosupplementation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate artery embolization. Findings:  The physician reviewers found that the medical evidence does not support the superior efficacy of the requested services in this clinical setting. The first line therapy for management of BPH includes medical therapy. This includes alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors and anticholinergic medication. The standard of care for management of patients with BPH who are not responding to medical therapy is transurethral resection of the prostate (TURP). In patients with very large glands, as in this patient, holmium laser enucleation of the prostate (HoLEP) and simple prostatectomy are considered the standard of care. Prostate artery embolization is a novel approach for treatment of patients with BPH. The current medical literature is limited to case series and retrospective comparisons. There is a lack of randomized trials that suggest improved efficacy of this modality over TURP, HoLEP or simple prostatectomy. Therefore, based on current medical literature, prostate artery embolization is not likely to be superior over standard treatment options for the treatment of this patient. Final Result: 3 of 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in urology 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 authorization and coverage for cardiac computed tomography angiogram (CCTA). This patient has multiple risk factors for cardiovascular disease. Her medications include antihypertensive and lipid lowering therapy. The patient underwent prior evaluation with a stress test, which was negative. The patient has symptoms of dyspnea on exertion and she is being treated for pulmonary disease as well. There is a lack of data supporting the use of CCTA in assessing the severity of coronary artery disease in a higher risk, symptomatic patient as a stand-alone test since it only detects calcified plaque. The American College of Cardiology (ACC) and American Heart Association (AHA) recommend CCTA for risk stratification of long-term cardiac risk in asymptomatic patients considered for risk reduction therapies like statins medication, lifestyle modifications and intensive diabetes management. In this instance, the patient is on a statin medication for her hyperlipidemia, amlodipine for blood pressure control, and metformin for diabetes to manage her cardiovascular risk factors. Thus, the requested CCTA is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Trexall. The patient has been diagnosed with alopecia areata (AA). Researchers reported that AA is an autoimmune disorder causing non-scarring hair loss. The authors also noted low-dose methotrexate appears to be an effective and well-tolerated treatment for recalcitrant AA multiplex. In this case, the patient has been diagnosed with AA and has been treated with steroid injections, steroid solutions, and Rogaine, which the patient reported were no longer effective. The Health Plan reported that Trexall will not be covered until the patient has tried other treatments first, such as generic methotrexate. There is no documentation in the record that states the patient has tried and/or failed treatment with generic methotrexate. The generic medication methotrexate and its branded version Trexall are chemically the same molecules and have the same pharmacologic and therapeutic activities. They can be used interchangeably for the same conditions. The only difference is the dose per tablet, but this is not enough to warrant one over the other for the treatment of this patient. The medical evidence does not support the requested medication in this clinical setting. Therefore, Trexall is not medically necessary for the treatment of this patient. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous iron infusions (INFeD).The current medical evidence supports the requested services in this clinical setting. Some individuals with reduced or absent iron stores who have not yet developed anemia may have symptoms, such as fatigue or reduced exercise tolerance, especially premenopausal women. Gastric bypass and other gastric surgeries, such as partial resection for ulcer disease or gastrectomy for gastric cancer, increase the risk of iron deficiency, as well as numerous other vitamin and mineral deficiencies. Intravenous iron is preferred over oral iron due to poor absorption and tolerability and is considered a standard of care in most gastric bypass patients. Therefore, intravenous iron infusions (INFeD) 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 board certified in internal medicine with sub-specialty certification in hematology 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 28-year-old female enrollee has requested for referral to an endocrinologist for treatment of her hyperthyroidism and type 2 diabetes.  Findings:  The physician reviewer found that the patient is at high risk for cardiovascular disease given her present BMI. In addition, the patient is not currently considered an ideal candidate for bariatric surgery due to risk for PE and DVT. Thus, management of her impaired glucose tolerance should be thoroughly evaluated by an endocrinologist for optimal medical therapy. Given the patients clinical presentation, a consultation with an endocrinologist is medically indicated for evaluation and treatment of her condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 29-year-old male enrollee has requested authorization and coverage for acupuncture for treatment of Tinnitus.  Findings:  The physician reviewer found that Tinnitus is a subjective sensation of hearing a sound in the absence of an external stimulus, which significantly worsens the quality of life of affected patients. A recent randomized clinical trial demonstrated the effects of acupuncture on tinnitus, and this modality was found to be effective in reducing the loudness and severity of tinnitus as well as in cases of non-pulsatile chronic tinnitus.  A comparative study demonstrated that different acupuncture techniques, including systemic manual acupuncture, periauricular electroacupuncture, and digital electroacupuncture, are effective in treating tinnitus. Therefore, in this patient with sensorineural hearing loss and tinnitus, the requested acupuncture is medically necessary. 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 otolaryngology 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 Sovaldi/Olysio 12-week combination therapy for treatment of her hepatitis C.  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences.  There is sufficient support for the requested medications in this clinical setting.  Therefore, Sovaldi/Olysio 12-week combination therapy is medically indicated for the treatment of this patient.  Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 63-year-old male enrollee, with a history of degenerative disc and joint disease, has requested authorization for physical therapy (PT) provided on the specified dates and prospective authorization for additional PT.  Findings:  The physician reviewer found that the patient had a flare of his condition and saw his provider following his previous PT regimen. The provider prescribed an additional 14 PT sessions. The patient had responded to PT in the past, and it was medically appropriate to attempt this therapy again. Considering that the patient has been previously trained for a home exercise program (HEP), six sessions with a reassessment and transition to a HEP should be adequate for treatment of his recurrence.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of her status post prior lumpectomies. Findings:  The physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: The 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Optune Tumor Treatment Fields Therapy (E0766) device for six months rental/six total units for treatment of the enrollees glioblastoma multiforme. Findings: Three physician reviewers found that Optune Tumor Treatment Fields Therapy has been approved for use in the treatment of glioblastoma.  It is a helmet-like device that is attached to the shaved scalp, and continuous treatment is recommended.  There are sufficient studies supporting the efficacy of this modality.  One study performed a randomized study of 210 patients with recurrent glioblastoma, comparing treatment with Novo-TTF with Temodar, versus Temodar alone.  There was improved median progression-free survival and median overall survival with the combination.  Clinical benefit was also seen in another study.  Therefore, Optune Tumor Treatment Fields Therapy (E0766) device for six months rental/six total units from 10/04/16 forward was and is likely to be more beneficial than other treatment options. Final Result: The reviewers determined that the services at issue were and 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: All physician reviewers are board certified in internal medicine with sub-specialty certification in medical 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

This patient is a 12-year-old male with a history of otitis media from ages three months to two-years requiring PE tube placement in March 1999. There is no documentation of effusion or hearing loss provided. The patient was seen for speech therapy from September 2004 through September 2005 for difficulty with /r/ in all positions. He had a previous evaluation in December 2002 that recommended speech therapy for similar problems. The enrollees mother is requesting reimbursement and continued authorization for speech therapy.  The Health Plan has denied this request based upon a determination that the therapy is not medically necessary.The September 2004 evaluation documents a loss of speech production of /r/ in all positions.  However, it does not show how significant the delays are. The September 2005 report documents that the patient can produce initial /r/ at the word and sentence level with 80% accuracy, which would be considered within a normal range. Medial and final /r/ are at a 60% level with cueing.  Based on the patients care and the duration of his inability to produce the /r/ sound, I would conclude that the problem is one of a developmental nature and not a medical one.  Additionally, I was unable to ascertain a correlation between the loss of /r/ in the patients speech production and the otitis media. The record did not include evidence of effusion or of a hearing loss. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.