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

The patients parent has requested authorization and coverage for occupational therapy services with providers certified in sensory integration therapy. To determine the medical necessity of ABA, research by Papatola and Lustig provides guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are: (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on this definition, the requested services are not medically necessary in order to treat the patients autism and associated conditions. Specifically, the patient does not meet section (c), as sensory integration therapy is not supported in the medical literature as an effective modality for the treatment of autism. In addition, it is unclear whether young patients who present with sensory-based problems have an actual distinct disorder of the sensory pathways of the brain or whether these deficits are simply characteristics associated with other developmental and behavioral disorders (Zimmer, et al.). A systematic review of studies employing sensory integration therapy for children with autism found limited evidence to support its effectiveness. Out of 25 reviewed studies, only three yielded positive results (Lang, et al.). Research indicates that when compared to behavioral methods, sensory integration therapies for children with developmental disorders do not exceed those gains made using behavioral methods alone. The physician reviewer found that these findings are consistent with the National Standards Project (NSP), which is currently the largest examination of research supporting interventions that target the core characteristics of autism in young patients on the autism spectrum. The NSP considers sensory integration therapy to be an unestablished intervention for the treatment of autism, meaning there is a lack of evidence in the scientific literature that allows firm conclusions about its effectiveness in patients with autism. Overall, the research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Given these findings, the requested occupational therapy services with providers certified in sensory integration therapy are 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.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested for a pelvic MRI to rule out adenomyosis. Findings:  The physician reviewer found that the MRI was ordered after an ultrasound of the uterus (during an IVF procedure) showed findings that were suspicious for the diagnosis of adenomyosis. The MRI was ordered to resolve the suspicious finding. An MRI is medically necessary to assist in the diagnosis of adenomyosis. It can be a more sensitive imaging modality than ultrasound. Additionally, an MRI can help avoid a tissue biopsy of the area, which is the gold standard for diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hysterectomy for treatment of the enrollees symptomatic fibroids and left ovarian cyst. Findings:  The physician reviewer found that the hysterectomy performed was medically necessary for treatment of the patients medical condition. Uterine myomas are the most common solid pelvic tumors in women and the leading indications for hysterectomy. The two most common symptoms for which patients seek treatment are abnormal uterine bleeding and pelvic pressure. The most common kind of abnormal bleeding is hypermenorrhea which often results in significant disruption of activities of daily living (ADL). Adenomyosis refers to a disorder in which endometrial glands and stroma are present within the uterine musculature. This gynecologic condition likewise causes heavy menstrual bleeding and often painful periods. Patients with adenomyosis often have other associated gynecologic problems such as endometriosis or leiomyomas, such as in this case. Because there are no standard diagnostic imaging criteria to make the diagnosis preoperatively, choosing the optimal treatment for this particular condition is challenging. Currently, hysterectomy remains the standard of care for surgical treatment for leiomyomas because it is the only definitive treatment and eliminates the possibility of recurrence. In addition, the management options for adenomyosis is a hysterectomy. Final Result: The reviewer determined that the surgery at issue was 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 obstetrics and gynecology 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 47-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer.  Findings:  The physician reviewer found that this particular case requires the use of MRI for detection of solid lesions in each breast as seen in this patients imaging history. In this case, the patients solid lesions were not seen on mammography or ultrasound. The fact the lesions have been called solid is an indication for follow-up MRI for further diagnostic purposes. Since the lesions are occult by mammography and ultrasound, it would not be possible to biopsy them to prove their probably benign etiology since they can be seen only with MRI and are not even palpable.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic LINX procedure. Findings:  Two of the three physician reviewers found the LINX device has been approved for patients with gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. This patient has symptoms consistent with gastroesophageal reflux. However, it appears the patient's reflux is neither advanced, as there was no endoscopic or histologic evidence of esophagitis, nor has the lower esophageal sphincter been demonstrated to be dysfunctional. The patient cannot be considered medically refractory to acid blocker drugs since the records document only a small dose of ranitidine. Additionally, the implantation of LINX in this setting must be approached with caution given the documented complaint of dysphagia. As such, the requested laparoscopic LINX procedure is not likely to be superior over other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified 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:  An enrollee has requested dialectical behavior therapy intensive outpatient program services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients fragmented ego, symptom burden, limited coping skills and self-defeating coping strategies increase the risk for relapse and a poor clinical outcome in the absence of appropriate treatment.  There is sufficient support for the services at issue in this clinical setting.  The specific therapy is an evidence-based treatment that benefits those with character pathology and addictive illness.  The setting allows for closer observation of symptom evolution during the delicate negotiation of pharmacologic management for this patient being treated with multiple psychopharmaceuticals.  There is an inherent complexity in this case as obsessive-compulsive disorder typically needs high-dose serotonergic enhancement while antidepressant medication can exacerbate bipolar illness, particularly the rapid cycling variant of the disorder.  Finally, the duration and frequency of programming afforded by the level of care enables re-visitation of identity formation, a developmental task that has been compromised for this patient, in addition to further consolidation of relapse prevention strategies.  The record reflects that the patient has been engaged in active treatment.  Both the setting and primary therapeutic modality are safe, appropriate and consistent with good medical practice.  All told, dialectical behavior therapy intensive outpatient program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested breast tomosynthesis for medical evaluation of her risk for breast cancer.   Findings:  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone.Final Result: Three reviewers determined that the services at issue were 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 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 is a 43-year-old female who is 51, weighs 210 pounds, and has a body mass index (BMI) of 40. She also has significant comorbid conditions including gastroesophageal reflux disease and dyspnea upon exertion. Previous attempts at weight loss have not been successful.  It is not known if the patient has received psychological clearance for weight loss surgery. The Health Plan has denied coverage for laparoscopic adjustable gastric banding (Lap-Band) based upon their determination that it is not medically necessary for treatment of the patients medical condition.The long-term success of the Lap-Band when measured in terms of maintaining excess body weight loss is inferior to the gastric bypass or duodenal switch operations. The limited result of the procedure does not come with limited risk. In a three-year follow-up study of 299 patients with the Lap-Band, 88% had post-operative complications ranging from reflux to stomach-band outlet blockage.  In this study one-fourth of the patients had the band removed.  This patient already has reflux disease according to her provider, so she is at even greater risk of complications with the Lap-Band procedure.  Based upon the information set forth above, I have determined the requested procedure 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 of Prempro. The U.S. Food and Drug Administration (FDA) approves the use of Prempro for the treatment of vasomotor symptoms due to menopause. The American College of Obstetricians and Gynecologists (ACOG) notes some patients aged 65 years and older may continue to need systemic hormone therapy for the management of vasomotor symptoms, and the use of hormone therapy and estrogen therapy should be individualized based on each patient's risk-benefit ratio and clinical presentation. In this case, the patient presented with vasomotor symptoms associated with menopause and had tried and failed alternative treatments. Given the provider has recommended continued use of the requested medication and the patient has reported relief, the requested medication is medically indicated in this clinical setting. Therefore, Prempro is medically necessary for the treatment of this patient.Final Result: The reviewer determined the medication at issue 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 obstetrics and gynecology 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 patient has been diagnosed with insomnia. The patient reported multiple issues, including insomnia. The provider discussed sleep hygiene with the patient and increased the dose of trazodone to 200 mg. The patient has requested authorization and coverage for a weighted blanket. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a weighted blanket is medically necessary for the treatment of the patients medical condition. Schutte-Rodin and colleagues reported, Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia. The authors also noted, Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible. In this case, the patients insomnia may be complicated by other underlying problems. Weighted blankets are not considered the standard of treatment in sleep practices or guidelines for insomnia treatment. The medical evidence does not support the requested equipment in this clinical setting. Therefore, a weighted blanket is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 sleep 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Hyperbaric Oxygen Treatment.Findings:  Two out of three physician reviewers found that the services at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. According to the American Academy of Otolaryngology-Head and Neck Surgery, when a patient presents with sudden sensorineural hearing loss, they should obtain an audiogram, MRI or ABR, and start corticosteroids as initial therapy. The guideline also states that the clinician may offer hyperbaric oxygen therapy combined with steroid therapy within two weeks of onset. Hyperbaric oxygen therapy can also be offered as salvage therapy if the patient does not improve with steroids alone. A systematic review and meta-analysis performed by researchers concluded that the addition of hyperbaric oxygen therapy to standard medical therapy is a reasonable treatment option for sudden sensorineural hearing loss, particularly for those patients with severe to profound hearing loss at baseline and those who undergo hyperbaric oxygen therapy as a salvage treatment with a prolonged duration. Researchers performed a systematic review that looked at seven trials, and they concluded that for people with acute idiopathic sudden sensorineural hearing loss, the application of hyperbaric oxygen therapy significantly improved hearing. These studies and published guidelines support that when a patient does not improve with steroids alone, the standard of care is to offer hyperbaric oxygen therapy for salvage therapy. Therefore, the Hyperbaric Oxygen Treatment services at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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 in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. 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
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 55-year-old man with knee pain secondary to arthritis. He has been treated with Synvisc injections over the past two years and has found them to be beneficial. The patients provider has requested authorization for a repeat series of Synvisc injections. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient is relatively young and has severe arthritis in his right knee.  Although he will eventually require knee replacement, the requested treatment with Synvisc may effectively delay the eventuality. The last series of injections was performed more than one year ago and resulted in significant pain relief and improved functionality. A repeat series of Synvisc injections is appropriate at this time to alleviate his pain and to postpone surgical intervention. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested Avastin for the treatment of her recurrent primary peritoneal carcinoma. Findings:  Two physician reviewers found that Avastin is a monoclonal antibody targeting VEGF. It is approved for the treatment of colon cancer, lung cancer and breast cancer. It has been studied in a number of other cancers, including primary peritoneal cancers. The use of Avastin in ovarian cancer (including primary peritoneal cancer) is endorsed by the National Comprehensive Cancer Network (NCCN). Based on the available evidence, the efficacy of Avastin in this setting has been sufficiently established.