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

The parent of a 19-year-old male enrollee has requested for residential psychiatric hospital services for treatment of the enrollees bipolar disorder and Aspergers syndrome. Findings:  The physician reviewer found that the patients behavior became aggressive and disruptive and required that he be treated with 1:1 staffing. He had continuing homicidal and suicidal ideas which were less intense than he previously held, but which still constituted a significant danger. He needed the supervision, staffing and structure of a residential facility.  Anything less would not have been safe and would not have met his medical needs.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that the patient is a female who had digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The patient has requested reimbursement for digital breast tomosynthesis performed.  The Health Plan has denied reimbursement for digital breast tomosynthesis as investigational/experimental for evaluation of this patient. The digital breast tomosynthesis performed was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: 2/3 of 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback and rectal sensation testing. Findings:  Three physician reviewers found that, based on the records provided, there is a lack of support for biofeedback and rectal sensation testing.  There is a significant amount of important information to be gained from a careful rectal examination as well as examination of the perineum during attempted defecation.  In many cases, anal manometry is not necessary.  In addition, many patients can have good continence with solid or semi-solid stool.  Controlling the diarrhea can obviate the need for biofeedback.  In sum, the superior efficacy of the requested biofeedback and rectal sensation testing has not been established. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for evaluation and 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 internal medicine with sub-specialty certification in gastroenterology 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: The parent of a five-year-old enrollee has requested additional hours per month of applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings: The physician reviewer found that ABA therapy is medically necessary for the treatment of patients with ASD. Reichow and colleagues found that early and intensive ABA could provide considerable benefits for children with ASD including improvements in cognitive skills, language and adaptive skills. In addition, Orinstein and colleagues found that children with optimal outcome from ASD started ABA between four and five years of age and were receiving 25 hours per week of therapy compared with 18 hours per week for those with high functioning autism. In this case, the patient has reached a number of goals with treatment. However, he has tantrums, although at much lower levels, and still has non-compliance behaviors.  He also has moderate level stereotypy requiring a higher level of ABA hours. The reduction of ABA services often leads to regression and worsening behavior. Thus, a reduction of ABA therapy hours per month as authorized by the Health Plan is likely to cause regression and a return of maladaptive behaviors. Thus, a portion of the requested number of hours per month of ABA therapy, supervision and home care training are medically necessary and appropriate for treatment of the patients ASD. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for a Zoll LifeVest. In this case, notes report that the patient underwent a dual chamber implantable cardioverter defibrillator (ICD) for secondary prevention of sudden cardiac death. A systemic bacterial infection required redo of aortic valve replacement (AVR) and device explantation of ICD leads and pulse generator. Procedure notes reported that the patient underwent subcutaneous ICD implantation. In this clinical setting, a Zoll LifeVest was appropriate during the patients treatment and recovery from the severe systemic infection that required a redo of heart valve surgery while the device was explanted until he was cleared by infectious disease to undergo a new ICD implant procedure. Therefore, a Zoll LifeVest was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Zoll LifeVest at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cystoscopy chemodenervation with botulinum toxin. Findings:  Two physician reviewers found that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Patients with neurogenic bladder can have significant detrusor overactivity leading to urinary incontinence. Anticholinergic medications are first-line therapy, and patients refractory to medications can be managed by minimally invasive therapies such as Botox injection and sacral neuromodulation. Botox injections have been shown to improve compliance and reduce detrusor overactivity in patients with neurogenic bladder refractory to medical therapy, such as in this case. According to the European Association Urology (EAU) guidelines Botulinum toxin injection in the detrusor is the most effective minimally invasive treatment to reduce detrusor overactivity. Final Result: Two reviewers determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in urology and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested  for IV therapy from an out-of-network provider for treatment of the enrollees pulmonary hypertension. Findings:  The physician reviewer found that this patient should be started on IV therapy as soon as possible. She needs to be managed by a pulmonary hypertension center experienced with its use.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested artificial disc replacement surgery with ProDisc (Code 22856, 38220 and 20930 for treatment of his cervical disc degeneration and cervical radiculopathy. Findings:  Three physician reviewers found that the patients medical history is significant for diabetes and he is noted to be taking Naproxen. At this time, the patients surgeon has recommended anterior discectomy with fusion (ACDF) and ProDisc-C artificial disc placement at these levels. At the present time, the Food and Drug Administration (FDA) has approved the ProDisc-C device pending completion of 5-, 7-, and 10-year follow-up studies to determine the long-term safety and efficacy of the device. Murrey and colleagues reported on early results, however as the durability and safety of the prosthesis remains unproven and the potential side effects remain unknown, the device is not likely to be more beneficial than any available standard therapy in this case.
Appeal type: Urgent Care
Decision: Overturned

A 71-year-old male has requested coverage for past hospital services provided him for seventeen days. The Health Plan has denied this request indicating that the enrollee was stable for transfer to a contracted hospital.  Findings:  The physician reviewer found that at issue in this case is whether the patient was stable for transfer at any point during the seventeen-day period under review. The patient developed an acute stroke as a procedural complication followed by acute chest discomfort, so transfer during this time period would not have been medically safe. However, by the second day of the time period at issue the patient was determined not to have an acute myocardial infarction and his neurologic symptoms had not progressed. No recurrent chest discomfort was reported and only mild asymptomatic sinus bradycardia was present. On this day, the patients medical conditions had stabilized enough to make transfer to a participating hospital safe.  Thus, the care provided for the final fifteen days of hospitalization was correctly categorized as post-stabilization care for which the provider did not seek authorization by the Plan before providing.  Hospital transfers after observing a patient for 24-hours in the setting of unstable angina, as well as hospital transfers after stroke, are safe and occur routinely as patients can be transported for appropriate care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy at a frequency of two sessions per week, for 30 minutes per session for treatment of the enrollees severe expressive language impairment.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of greater than 50%. Speech therapy is indicated with any delay greater than 25% (Feldman & Messick).  An extensive review of the literature, including meta-analysis by Law et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman & Messick). This patient has a history of severe expressive language delay and should receive appropriate intervention including speech therapy at the requested frequency.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested reimbursement for enhanced external counterpulsation (EECP) therapy for treatment of coronary artery disease.  Findings:  Three physician reviewers found that the use of external enhanced counterpulsation therapy (EECP) in the treatment of chronic stable angina, refractory to medical and not amenable to revascularization procedures has been a well accepted, non-experimental use of this technology in selected anginal patient subsets. The use of EECP in the treatment of heart failure - although early trials show promise - has not yet shown benefit in this patient subset. There are patients who present with crossover symptoms such as dyspnea which may be an anginal equivalent in patients who are not amenable to revascularization procedures; however this patient from review would be a suitable candidate for repeat revascularization procedures if recurrent ischemia is a concern.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether the implantation of a hypoglossal nerve stimulator is likely to be more beneficial for the treatment of the patients condition than any available standard therapy. The patient had a diagnosis of sleep apnea. She is status post uvulopalatopharyngoplas. She reported that she discontinues continuous positive airway pressure (CPAP) ty (UPPP) and turbinate reduction.Findings:  Two out of three physician reviewers found that the medical literature demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This procedure is recognized by the American Academy of Otolaryngology Head and Neck Surgery to be an effective second-line treatment of moderate to severe obstructive sleep apnea. In this case, the patient has a body mass index and apnea-hypopnea index within appropriate parameters, and a nonconcentric airway collapse, thereby meeting the criteria. She has failed CPAP. She has failed previous sleep surgery. Therefore, implantation with a hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One out of three physician reviewers found that there is a lack of support for the requested services in this patients case. Her compliance data confirmed that the patient does well on the CPAP and benefits from treatment.  She has had several surgical procedures on her upper airway and nose.  She has not used an oral appliance, which is a good alternative to patients that are CPAP intolerant.  Therefore, implantation with a hypoglossal nerve stimulator is not 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 procedure 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: Physician reviewers 1, 2 and 3 are board certified in board certified in otolaryngology 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 53-year-old female enrollee has requested a lumbar laminectomy for treatment of her back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient has chronic lumbar spine pain.  The submitted records do not include objective evidence of six weeks of non-operative therapy for this patient, as physical therapy notes and interventional injection notes were not provided for review.  There is lack of documentation of significant neurological findings on clinical examinations.  The current medical evidence does not support the requested services in this clinical setting.  The submitted records do not demonstrate significant neurological deficits, and there is a lack of documentation of conservative care.  All told, the requested lumbar laminectomy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old male has requested a left knee/patella osteochondral allograft procedure for treatment of his osteochondritis dissecans of the patella.  Findings:  Two physician reviewers found that per the medical records, the patients condition has not responded to conservative treatment.  Additionally, the submitted documentation noted prior open bone grafting and fixation in an attempt to heal the lesion of the patella.  The provider reported that the patient has symptomatic knee pain with any weight-bearing activity.  In this patients case, the requested services are likely to be superior over other available treatment options.  There is limited support in the medical literature for osteochondral allograft of the patella, although this is due to the rarity of this condition.  There are limited treatment options in this clinical setting.  These treatment alternatives include patellectomy and arthroplasty.  This patient is too young for arthroplasty, and patellectomy should remain as a salvage procedure if other treatments fail.  In this case, the requested left knee/patella osteochondral allograft procedure is likely to be of greater benefit than the other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Tecfidera 240 mg capsule for treatment of the enrollees multiple sclerosis. Findings: The physician reviewer found that Tecfidera is U.S. Food and Drug Administration (FDA) approved for relapsing forms of MS. This patient has active MS and needs to be on a therapy that is likely to be more effective than an interferon. In addition, she has had significant injection site reactions and would prefer to be treated with an oral agent. Moreover, the patient has been on Tecfidera for three months and is tolerating it well. Given this support, the requested Tecfidera 240 mg capsule is supported as medically necessary for treatment of this patients MS.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 internal medicine and neurology 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: The patients parent has requested authorization and coverage for Palforzia. Findings: The records provided for review document that this patient has a history of peanut allergy. A study noted that, In patients with peanut allergy, high-certainty evidence shows that available peanut oral immunotherapy regimens considerably increase allergic and anaphylactic reactions over avoidance or placebo, despite effectively inducing desensitization. The authors concluded that, Safer peanut allergy treatment approaches and rigorous randomised controlled trials that evaluate patient-important outcomes are needed. On review of the available records, there is a lack of support for treatment with Palforzia for this patient. Although oral immunotherapy has been demonstrated to be an acceptable therapy to attempt to induce desensitization in well-selected patients, there remains a higher risk of adverse reactions while undergoing oral immunotherapy. The records do not support that this patient meets the criteria for treatment with Palforzia given the lack of recommendation from the provider for the patient to receive oral immunotherapy. Therefore, the requested Palforzia is not medically necessary for 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 internal medicine with subspecialty certification in allergy and immunology 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.