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

A 62-year-old female enrollee has requested IVIG therapy for treatment of her dermatomyositis. Findings:  The physician reviewer found that the medical records indicate that she was in a wheelchair prior to high-dose IVIG and that she failed multiple steroid-sparing therapies prior to initiation of IVIG. IVIG is a well-established therapy for refractory polymyositis and dermatomyositis and has been used successfully for years(Dalakas and colleagues). In the Dalakas trial, IVIG resulted in clinical improvement in inflammatory myopathy, but the duration of benefit was short and repeated treatments were needed. Review of the literature failed to find evidence for an optimal length of treatment with immune globulin. Thus, duration of treatment depends upon the clinical findings in an individual patient. Therefore, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested continued post-acute inpatient rehabilitation services for medical treatment of his medical conditions.  Findings:  The physician reviewer found thatthe patient was documented to have made improvements in various areas of his treatment that include improvements with cognitive and behavioral components, and independence with wheelchair propulsion and stair negotiation. Although several areas of concern remain as to his ability to return to independent care and participation in his daily activities, his overall condition was determined to be stable. Based on the clinical documentation demonstrating improvements in multiple areas, the services at issue were not medically necessary and the patient could have been treated at a lower level of care. Therefore, continuation of post-acute inpatient rehabilitation services was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left total hip replacement surgery. The American College of Rheumatology (ACR) recommends total joint arthroplasty for patients with hip osteoarthritis following failure of adequate attempts at medical therapy (Hochberg, et al.). Conservative treatment options for the treatment of patients with hip osteoarthritis include exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. Per Hochberg and colleagues, Pharmacologic modalities conditionally recommended for the initial management of patients with knee osteoarthritis included acetaminophen, oral and topical NSAIDs [non-steroidal anti-inflammatory drugs], tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. The authors noted, Recommendations for hip osteoarthritis were similar to those for the management of knee osteoarthritis.This patient is being treated for left hip degenerative joint disease. Her provider has recommended left total hip replacement. The patient reports left hip pain occurring both at rest and at night, and her pain is rated 8/10. The records document that treatment with cortisone injections have not provided substantial relief of the patients symptoms. However, there is a lack of detailed documentation of trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures prior to consideration for surgical intervention. The records do not report failure of medication, physical therapy, or home exercises. Moreover, there is a lack of evidence of worsening symptoms or pain levels, and the objective findings did not demonstrate any worsening range of motion. For these reasons, the requested left total hip replacement 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a ProAir HFA albuterol inhaler for treatment of her medical condition.  Findings:  The physician reviewer found that the requested medication has not been established as medically necessary for treatment of the patients medical condition. The management of asthma per the Global Initiative for Asthma (GINA) guidelines divide asthmatics by their degree of control and based on that determine what step of treatment they require. All five steps have as their foundation the use of short acting beta agonists (albuterol) to achieve immediate relief during an acute worsening of asthma symptoms. The efficacy of short acting beta agonists for the management of acute asthma is long proven. In this case, the patient is requesting ProAir, an ethanol containing preparation. However, she has been authorized for treatment with Ventolin HFA albuterol. There is lack of rationale supporting this request or evidence of treatment failure. All told, ProAir HFA albuterol inhaler has not been established as medically necessary for treatment of the patients medical condition.  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 sub-specialty certification in pulmonary disease and critical care 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

A 41-year-old female enrollee has requested Tysabri injections for treatment of her multiple sclerosis.   Findings:  The physician reviewer found that although the patient has a diagnosis of multiple sclerosis, the submitted records do not include confirmatory evidence to support the diagnosis. Based upon the information submitted, the patient is not currently assessed with a relapsing form of multiple sclerosis. The patients neurologist ordered several tests, the results of which have not been provided. Before it can be determined if a change in therapy is indicated, the diagnosis of multiple sclerosis must be confirmed, neuromyelitis optica should be ruled out and documentation of recent relapse should be provided. In the absence of such evidence, Tysabri is not medically necessary for treatment of the patients 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 speech therapy. The submitted documentation supports that the requested services are medically necessary. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. In this case, the patient has a severe articulation disorder, as documented by two speech pathologists and as evidenced by two speech evaluation tools. The research on articulation disorder confirms that individual speech therapy may be critical in preventing the patient from being placed at risk for life-long disability. The present request for speech therapy, one time per week for 60 minutes, is reasonable and appropriate. Accordingly, the requested speech therapy, one time per week for 60 minutes, is medically necessary for the treatment of the patient's medical condition.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 both pediatrics and neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX testing.Findings: Two of the three physician reviewers found that the ThyGenX testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment. While a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of deoxyribonucleic acid (DNA) mutations and ribonucleic acid (RNA) translocation fusion markers to assess the risk of malignancy, with good negative and positive predictive value. ThyGenX testing may allow patients to avoid unnecessary surgeries. There is sufficient support for the services at issue in this clinical setting. Therefore, ThyGenX testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment.Final Result: Two of the three reviewers determined that the ThyGenX testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard 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 subspecialty certification in endocrinology, diabetes and metabolism, and all three 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

The parent of a two-year-old male has requested past and future coverage for speech therapy twice per week for 12 weeks for treatment of his speech delay.   Findings:  The physician reviewer found that based on review of the available records, this young patient has an identified delay in receptive and expressive speech of greater than 40%. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the recommended speech therapy twice per week for 12 weeks was and is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee has requested substance abuse rehabilitation services for treatment of her alcohol dependence, cannabis dependence, nicotine dependence, alcohol withdrawal, cannabis withdrawal and hypertension.   Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue. In general, modern psychiatric practice aims to provide care at the least restrictive setting that is likely to effectively address the issues driving the symptom complex or pathological behaviors which cause functional impairment.  Providers rely on clinical judgment in the context of practice guidelines, peer-reviewed literature and placement criteria to assist with level of care determination process.  In this case, the patients alcohol use had dominated multiple domains of functionality.  She had participated in community programming, but could not achieve sustained sobriety.  Her excessive daily drinking culminated with a potentially fatal blood alcohol level.  Per the submitted records, her living environment and social setting were unable to support her sobriety.  This patients longitudinal history, psychosocial situation, and severity of the symptom complex justified specialized treatment in a structured, 24-hour supervised setting.  The services provided were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, substance abuse rehabilitation services were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 21-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary frequency and urge incontinence.  Findings:  Two physician reviewers found that the available peer-reviewed medical literature, there is a paucity of reproducible data demonstrating the long-term safety and efficacy of the requested procedure. There is a need for additional randomized, controlled clinical trials to permit conclusions regarding a role for PTNS in treating urinary frequency or urgency. Therefore, the requested PTNS is not likely to provide this patient with greater benefit than standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that the addition of digital breast tomosynthesis to standard digital mammography has been shown to increase the detection of small cancers, particularly in dense or heterogeneously dense breast tissue. This patient was noted to have heterogeneously dense tissue on her mammograms. Currently, there is a lack of long-term studies showing increased survival rates using digital breast tomosynthesis. However, the addition of digital breast tomosynthesis to screening mammogram imaging is becoming more common due to the data demonstrating its advantages. Therefore, breast tomosynthesis was likely to have been more beneficial for evaluation of this patients medical condition than any available technique. Final Result:  Two reviewers determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology 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: Upheld

A 50-year-old female enrollee has requested for saphenous vein ablation for treatment of her varicose veins. Findings:  The physician reviewer found that there is no evidence in the submitted medical record indicating that the patient has symptoms interfering with her daily activities. There is no evidence that any conservative measures have been tried aside from elevation. There is no evidence that compression stockings were used and no follow-up provider note correlating the patients symptoms with venous Doppler findings.  All told, the submitted documentation does not include sufficient information regarding symptoms and conservative treatment tried.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging. The indications for breast MRI include high and intermediate risk screening, for patients with a new diagnosis of breast cancer, for evaluation of response to chemotherapy prior to surgery, for evaluation of recurrence and metastatic cancer of an unknown primary source, and when mammographic and sonographic findings are inconclusive. In this case, if the asymmetry visualized on diagnostic mammography remained suspicious, then stereotactic biopsy is indicated. The records do not suggest that the breast asymmetry is concerning for implant rupture or that biopsy is not technically feasible. Accordingly, the requested breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested breast MRI is 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 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 reviewer 1 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 3 is 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx-Melanoma test for evaluation of the enrollees malignant melanoma. Findings:  Three physician reviewers found that DecisionDx-Melanoma is a 31-gene expression profile used to determine the risk of recurrence of melanomas. The National Comprehensive Cancer Network guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low-risk versus high-risk of metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanoma is not recommended outside of a clinical study. Per the National Comprehensive Cancer Network guidelines, there is no confirmation that the results of such genetic profiles have an independent prognostic value. Final Result: The 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: Reviewers 1, 2 and 3 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

A 45-year-old female enrollee has requested a lumbar spinal fusion for treatment of her low back pain. Findings:  The physician reviewer found that fusion in the lumbar spine is generally accepted in cases of instability associated with trauma, tumor, or infection, and in scoliosis and spondylolisthesis, but other indications are variable and not accurately defined. Arthrodesis remains controversial for the treatment of discogenic back pain. With an established indication, improvement can be expected after fusion, although patients with chronic low back pain experience less improvement. The presence of disc degeneration can be noted in the absence of back pain or any other symptoms. Lumbar discography also remains controversial, with reports of false-positive findings and abnormal results in normal subjects.  In this case, there is no documentation of instability of the spine, and the discogram is not definitive. The submitted documentation fails to establish the medical necessity of the requested lumbar spinal fusion in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee has requested for a whole body Positron Emission Tomography (PET) scan for evaluation of her possible lymphoma. Findings:  Three physician reviewers found that there is not a known diagnosis of cancer, or even findings from other imaging tests to assess metabolic activity in order to warrant a whole body PET scan. This patient has a perplexing set of clinical symptoms. However, all diagnostic tests have been negative to date. Also, no abnormal clinical findings (such as adenopathy or palpable masses) or prior scans exist to warrant evaluation by a whole body PET scan. Presently, PET scans are performed for specific reasons such as those listed, and there is no current medical literature to support the use of a whole body PET scan to evaluate peculiar or strange symptoms without a histological diagnosis of malignancy, or to evaluate a finding on another imaging modality to assess metabolic activity. For these reasons, a whole body PET scan in this case would likely be without benefit.