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

A 60-year-old male enrollee has requested intravitreal Avastin injections for treatment of his diabetic macular edema. Findings:  Two physician reviewers found that the medical literature is replete with studies in support of the effectiveness of anti-vascular endothelial growth factor (VEGF) medications (such as Avastin) in the treatment of diabetic macular edema. Kook and colleagues conducted a recent prospective study of 126 patients with chronic diabetic macular edema who underwent treatment with Avastin. The authors concluded that, Even in cases with chronic diffuse ischemic diabetic macular edema, a long-term decrease of central retinal thickness can be observed following repeated intravitreal injections of bevacizumab, which in turn, resulted in improved visual acuity. All told, there is sufficient literature support for the use of Avastin in this setting to warrant its use by this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested Ciclopirox 8% solution for onychomycosis. The enrollee saw his primary care physician and got a prescription for Ciclopirox 8% solution, presumably during this visit, although there is no mention of this in the plan.  Lab tests were ordered, but no hepatic panel was done to see if the enrollee would be able to take oral antifungal medication.  In addition, there is no mention of onychomycosis as a diagnosis in the enrollees note from his visit.  There is insufficient evidence in the medical record showing the enrollee has onychomycosis.  The medical literature has shown that Ciclopirox is significantly more effective in the treatment of onychomycosis caused by Trichophyton rubrum, but without a documented culture, it would be difficult to know if this medication would even be beneficial for this enrollee.  Another study done with Ciclopirox 8% showed a lack of penetration of the nail plate in sufficient concentrations to prevent the growth of Trichophyton rubrum and thereby showed that it lacked any antifungal efficacy. Other studies have shown that the cure rate achieved with Ciclopirox 8% during clinical trials has proven less than impressive. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 12-year-old male with an apparent diagnosis of Tourettes syndrome, bipolar disorder and oppositional defiant disorder. The patient is treated with psychotherapy and medical management. Reportedly, Catapres TTS-3 (clonidine) patches applied daily are more effective in controlling the patients tics and behaviors than any other clonidine regimen. At issue is whether a quantity of 28 Catapres TTS-3 patches every 28 days is medically necessary for treatment of the patients condition.Clonidine is an anti-hypertensive and has many possible side effects or adverse reactions, especially in children.  Topamax, Seroquel, Abilify and Prozac have also been prescribed for the patient. The patients current protocol of one Catapres TTS-3 patch per day has been in place for three years without a report of serious side effects. The patients parents apparently consent to this specific use of clonidine. The submitted evidence suggests the patients parents and his prescribing physician follow the patient very closely and believe the benefits of the patients current regimen outweigh the risks. As such, it appears that continuation of the patients current regimen is medically appropriate. However, it should be ensured the patient maintains a normal blood pressure for age, and the parents, or an appropriate caregiver, should monitor the patients blood pressure on a daily basis.Based upon the information set forth above, I have determined that the requested prescription is medically necessary for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a nine-year-old female with a history of receptive speech and expressive speech language delays. She shows no other symptoms consistent with autism as documented by the neuropsychologist and developmental pediatrician. The patient shows no fine motor delays as documented by her occupational therapist. She has been receiving speech therapy since the age of three and a half. The patients therapist documents continued delay and is recommending continued therapy. At issue is whether speech therapy is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Based upon the information provided, there are no medically based issues warranting additional therapy. The primary issues are educational in nature as documented in the speech therapy letter dated 6/1/05 and in the daily notes. Most of the submitted clinic notes document problems with vocabulary, grammar and homework. In the absence of a more specific diagnosis, additional speech therapy is educational in nature and not medically indicated. Therefore, I have determined that 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for xanthelasma removal. Findings:  The physician reviewer found that records and photographs provided for review support that this patient presents with a recurrent xanthelasma, which is a collection of lipid deposits under the eyelid skin. As discussed by Laftah and Al-Niaimi, treatment options include topical trichloroacetic acid, liquid nitrogen cryotherapy, and lasers. The authors reported that surgical excision often yields excellent outcomes, but the incidence of recurrence is increased in patients who undergo incomplete excision. The authors concluded that surgical excision is the mainstay of treatment for xanthelasma lesions that involve the deep dermis or infiltrate the underlying muscle. In this patients case, the xanthelasma has failed to respond to treatment with hyfrecation and liquid nitrogen cryotherapy. Consistent with the recommendations in the medical literature, the requested surgical excision is likely to provide a more definitive treatment for this patient. Therefore, the requested xanthelasma removal is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Although benign, xanthelasma is an abnormal structure of the body. The records do not document a functional problem related to this patients xanthelasma. However, based on the available documentation and photographs, surgical excision would provide a more than minimal improvement in the patients appearance. Thus, the requested xanthelasma removal is reconstructive in nature for treatment of this patient. All told, the requested xanthelasma removal is medically necessary and reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 Sovaldi and Daklinza for 24 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that per the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines, daily sofosbuvir and weight-based ribavirin plus weekly peginterferon for 12 weeks is recommended for interferon-eligible, treatment-naive patients with HCV genotype 3 infection, as a Class I, Level A rating. Daily daclatasvir and sofosbuvir for 12 weeks (no cirrhosis) or 24 weeks with or without weight-based ribavirin (cirrhosis) is recommended for treatment-naive patients with HCV genotype 3 infection, a Class IIa, Level C rating for cirrhosis. In this case, the patient is not interferon intolerant. The treatment regimen of Sovaldi, ribavirin and peginterferon for 12 weeks has a shorter treatment duration and is associated with superior results compared to the requested regimen. As such, the requested regimen of Sovaldi and Daklinza for 24 weeks has not been established as medically necessary for treatment of this patients hepatitis C virus. Final Result: The reviewer determined that the requested medications 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 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

An 18-year-old female enrollee whose parents requested authorization and coverage for the enrollee to continue treatment with a pediatric nephrologist with a special expertise in focal segmental glomerulosclerosis (FSGS).  The enrollees health plan denied this request indicating that the requested services are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested continued treatment with a pediatric nephrologist with a special expertise in FSGS is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 3-year-old male enrollee has requested  speech therapy twice per week and occupational therapy for 10 hours per month for treatment of the enrollees autism. Findings:  The physician reviewer found that language deficits are one of the core aspects of autism, and speech therapy provides professional help and guidance in communication development for individuals with autism (Volmar and Weisner). Further, Stone and Yoder evaluated 34 children with autism at 2 years of age with re-evaluation 2 years later to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. Overall, patients treated with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions in peer-review research articles published over the past 20 years and found that the evidence supports the efficacy of interventions to teach communication skills to children with autism. The authors reported that language skills can make a tremendous difference in the ability of children to control their environment. Similarly, language skills have been found to be an adaptive alternative to highly disrupted forms of communication such as self-injury or aggression. This patients speech and language evaluation indicates significant impairment for which speech therapy, twice per week, is medically indicated. With regard to the requested occupational therapy, an evaluation performed on said date did not identify any gross motor or fine motor deficits. The issues noted by the therapist consisted of sensory abnormalities, i.e., deficits involving the tactile sense and taste/smell sense. Although anecdotal evidence exists in support of occupational therapy for patients with sensory processing deficiencies, the treatment does not have sound evidence for effectiveness. To date, there are few well-controlled studies examining occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life. At this time, no firm conclusions can be made regarding specific approaches due to poor study quality and great variability in interventions. Given that this patients occupational therapy evaluation failed to identify any gross or fine motor deficits with regard to functional activities as well as the lack of evidence supporting occupational therapy for sensory processing deficits, the requested occupational therapy is not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested intensive inpatient feeding program for treatment of the enrollees feeding difficulties.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. In this case, the patient is three years old and has a feeding aversion that is severely limiting his oral intake and nutritional status as well as his weight. The patient is in the 8th percentile for weight and has iron deficiency anemia due to lack of nutrition. The patient is also unable to take oral medications, which has led to unnecessary procedures. The patient has been treated with many months of outpatient feeding therapy as well as occupational sensory therapy with minimal improvement. The patient chokes and gags when new food is offered. The patient needs a more intense program so he can begin to improve quickly. If this therapy is delayed he will continue to have issues that will only become worse as he gets older. There is support in the medical literature demonstrating that inpatient therapy is a safe and effective way to increase oral feedings and decrease feeding aversion in children that have failed outpatient therapy. Furthermore, children improve quicker with a multidisciplinary approach and this can be best achieved through an intensive inpatient feeding program. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested the Optune system (formerly known as NovoTTF-100A) for medical treatment of his glioblastoma multiforme. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) approved the NovoTTF-100A System (now Optune) for the treatment of adults with glioblastoma multiforme that recurs or progresses after receiving chemotherapy and radiation therapy. Based on the available data, Optune is medically necessary for this patient presenting with recurrent glioblastoma multiforme, after surgical resection, concurrent chemoradiation and adjuvant chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50% with mild delays in receptive speech. Speech therapy is indicated with any delay greater than 25%.  (Feldman & Messick). The literature includes a meta-analysis by Law, et al., in which the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty was noted. Feldman & Messick state that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). In accordance with the available peer reviewed medical literature and the medical records provided, this patient has a history of severe expressive language delay and should receive appropriate intervention including speech therapy. Thus, speech therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for a positron emission tomography with computed tomography attenuation (PET/CT) scan for the full body (CPT code 78816) and if that was not approved then she requested coverage for a PET/CT scan from skull to mid-thigh (CPT code 78815). The enrollee has recurrent right infiltrating ductal breast cancer. She has undergone a double mastectomy, a hysterectomy, and received hormonal therapy. She found another small mass approximately 4 years after treatment. The provider recommended PET scan with CT attenuation to check for the spread of the disease (metastases) and for re-staging of her disease. The literature shows a PET/CT is more sensitive and specific than bone scan for detection of the presence of bone metastases and will also show the presence of soft-tissue metastases. Done as a single study, it is more efficient than having the patient undergo multiple studies, such as a bone scan and CT scan. The PET/CT is a study indicated for this enrollee and is more sensitive and specific in detecting disease than bone scan, leading to earlier detection and earlier treatment of any metastatic disease detected for the enrollee. The use of a PET scan to restage advanced or recurrent breast cancer and monitor response to therapy is accepted and widespread. There is lymph node involvement with this enrollee so it is important to assess if there is further involvement of cancer throughout the body because there is increased risk of further spread that could be missed if not scanned.     Final Result: Two of three reviewers determined that the requested service of full body PET/CT scan is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in medical oncology and one is board certified in radiation oncology. All three reviewers 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microwave ablation of the lung. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees lung cancer. A review of the records indicates the enrollee has been diagnosed with lung cancer. The enrollee is being treated for a slow growing left upper lobe pulmonary nodule. A CT lung cancer screening reported to have shown suspicious nodule(s), and an enlarging left upper lobe pulmonary nodule. A biopsy was recommended, and the patients treatment plan included CT guided microwave ablation. The enrollee has noted that the alternative therapy is left upper lobectomy by thoracic surgery, which is more invasive, more expensive, and has a longer recovery with higher risk of complications. The submitted documentation does not support that the requested treatment is medically necessary at this time. Currently, there are no peer-reviewed studies that indicate a better outcome with  thermal ablation (radiofrequency ablation or microwave ablation) for a lesion with scar and atypia versus standard medical treatments of serial CT scans or chemotherapy (if the cancer is small cell). In this case, the size and location of the lesion, would make him a candidate for the requested treatment if there were biopsy proven non-small cell lung cancer. At this time, the patient may still be followed with repeat CT, followed by repeat biopsy if there continues to be growth. If biopsy then yielded histologically proven non-small cell lung cancer and the patients circumstances were otherwise unchanged, the requested treatment would be more consistent with medical literature. Accordingly, microwave ablation of the lung is not medically necessary for treatment of the patients medical condition at this time.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 both diagnostic radiology and interventional 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lumbar spine, cervical spine, and thoracic spine. Findings:  The physician reviewer found that the records show continued pain well after the Harrington Rod placement with MRI of a previous year. The patient continues to have pain but there is no fracture seen within the thoracolumbar spine on post-accident plain films and no fracture in the cervical spine on CT exam the day of her MVA. She continues to have pain but there is still no neurological deficit or other red flag to mandate spinal imaging prior to commencement and completion of a conservative trial of management including physical therapy with documented notes and continued evaluation. All told, the requested MRI of the lumbar spine, cervical spine, and thoracic spine are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedures 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 diagnostic 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.