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

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of past and future psychotherapy sessions provided once per week. At issue in this case is whether individual psychotherapy sessions provided once per week were and/or are medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that the patient is being treated for generalized anxiety disorder and attention deficit/hyperactivity disorder. The records document that the patient had made adequate progress with treatment. She has no urges to harm herself or others. She did not have any difficulties with psychosis or unstable medical issues. The patient was able to perform activities of daily living. The record noted that her therapy goals were a psychodynamic approach to look at factors involved in the family dynamic. Additional issues in therapy have included identification of sources of strength and support, continuing to manage high levels of anxiety surrounding family relationships, and improving her sense of security in regards to family relationships. There is no documentation of the patient showing symptoms or issues related to a mental health condition which would require once weekly therapy level of care. Based on the record, this patient has been doing well and has not demonstrated any acute symptoms. There is no plan of titration or termination of therapy, and no specific measurable goals have been stated. Decreasing the frequency of therapy sessions is reasonable based on the patients symptomatology. Although, there are no national criteria for psychotherapy frequency, this patients psychological state is stable, and psychotherapy can be titrated down with development of a plan for termination. Therefore, individual psychotherapy sessions, both past and future, provided once per week were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were not and 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 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

A 63-year-old female enrollee has requested a wireless capsule endoscopy for the evaluation of an ileal lesion.Findings:  Three physician reviewers found that it is the standard of care to fully evaluate the small bowel in this setting. Capsule endoscopy is more sensitive than standard diagnostic techniques and can better identify a lesion in the distal ileum.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested PET scans for evaluation of his cholangiocarcinoma. Findings:  The physician reviewer found that review of the scientific literature reveals several papers supporting the use of PET in patients with cholangiocarcinoma. The sensitivity and specificity of PET (alone or PET/CT) are 92-94% and 93-100% respectively, which is better than CT alone. PET/CT is particularly valuable in detecting unsuspected distant metastases, which are not diagnosed by standard imaging. Thus, PET/CT staging has an important impact on selection of adequate therapy. PET/CT resulted in a change of management in 10-30% of patients.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male has requested speech therapy twice per week for 60 minute sessions for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient has severe language deficits associated with the behaviors of ASD. Specifically, speech and language deficits are one of the core aspects of autism and appropriate speech therapy provides the professional help and guidance in communication development for autistic patients. Stone and Yoder found that at two-year follow-up, most patients with ASD developed useful speech or at least improved in their language development. The authors noted that chronological age, lack of typical prerequisite skills, or failure to benefit from previous language intervention, should not preclude speech therapy services from being provided when indicated. The only significant predictors were motor imitation and number of hours of speech therapy. In addition, Goldstein reviewed communication intervention in the peer-reviewed research articles published over the past 20 years and concluded that the evidence supported interventions to teach communication skills to children with autism including speech therapy. All told, language skills can make a significant difference in the ability of young patients to control their environment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested for an F-DOPA PET scan of the brain for evaluation of his parkinsonism. Findings:  Three physician reviewers found that the routine use of the PET scan with respect to neurological conditions is limited to localization of seizure foci in patients prior to surgical intervention. The use of PET scan (including F-DOPA) for other neurological conditions is generally still in the context of clinical trials or other investigational studies. A review of the peer reviewed literature affirms that the diagnosis of Parkinsons disease is currently based on clinical assessment; imaging studies are not routinely utilized to confirm the diagnosis
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested genetic testing for evaluation of his symptoms of Kearns-Sayre syndrome.  Findings:  Two physician reviewers found that Kearns-Sayre syndrome is a progressive and debilitating disorder which can result in progressive cardiomyopathy and fatal arrhythmias, progressive ophthalmoplegia and progressive retinopathy resulting in blindness, hearing loss, progressive muscle weakness, ataxia, and bone marrow suppression.  The diagnosis of Kearns-Sayre syndrome requires the identification of a mitochondrial DNA mutation or deletion detected through molecular testing including mitochondrial DNA sequencing.  If the diagnosis is confirmed by detection of mitochondrial DNA deletions, then the patient is at high risk for all of these complications and should be monitored closely.  If the diagnosis is confirmed in this patient, her clinical management and outcome will change. All told, the requested genetic testing is likely to be more efficacious than other available tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is repeatedly described as being motivated and responding well to staff suggestions. The treatment notes indicate that patients problem is his lack of experience with normal eating. The patients model for eating is described as continuous grazing of food most of the day and eating in front in of the television set. This type of education and role modeling could safely be conducted at a less intensive level of care than residential. In addition, the patient was not restricting or purging and did not have any major medical problems. Finally, the patient never expressed any suicidal thoughts and was compliant with his program. Therefore, the patient does not meet the criteria for 24-hour level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 41-year-old woman with a history of chronic lateral epicondylitis. She wishes to undergo extracorporeal shockwave therapy. The Health Plan has denied authorization and coverage for extracorporeal shockwave therapy on the basis that it is considered investigational.The requested therapy is not the standard of care at this time. There have not been sufficient studies establishing the benefit, risks, and outcomes of extracorporeal shockwave therapy for treatment of lateral epicondylitis. Furthermore, there is no class I peer-reviewed data to demonstrate that extracorporeal shockwave therapy is better for long-term relief of chronic lateral epicondylitis than standard therapy. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient has failed non-operative standard therapy. In addition, the patient has depigmentation and muscle atrophy contraindicating additional cortisone injections. The patients provider has recommended extracorporeal shockwave therapy (ESWT). The Health Plan has denied authorization and coverage for ESWT on the basis that it is considered investigational. The patient has failed prior therapy and is not likely to benefit from continued conservative therapy. ESWT is a known intervention and good outcomes have been reported. Furthermore, ESWT is less invasive than surgery. Since ESWT may obviate the need for surgical intervention, it is medically reasonable and appropriate for the patient to undergo ESWT. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3The patient is a 41-year-old woman with longstanding lateral epicondylitis. She has attempted treatment with injections of Xylocaine and Kenalog but has persistent pain. The patient wishes to undergo extracorporeal shockwave therapy for treatment of lateral epicondylitis. The Health Plan has denied her request on the basis that extracorporeal shockwave therapy is considered investigational.Extracorporeal shockwave therapy for treatment of lateral epicondylitis is not considered to be standard of care. A recent article in the Journal of Bone and Joint Surgery found that the procedure had little benefit and therefore, was not recommended. The current scientific literature does not demonstrate the efficacy of the requested therapy or the associated complications or risks. Therefore, the patient should be treated with standard of care modalities.Based upon the information set forth above, I have determined that the requested therapy is 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested a WalkAide functional electrical stimulator (FES) for treatment of her multiple sclerosis.   Findings:  Two physician reviewers found that FES devices have become more common use for patients with foot drop due to upper motor neuron lesions. The devices are prescribed for patients with multiple sclerosis. The peer-reviewed medical literature supports gait improvements beyond gains made with an AFO. This patient has had a trial with the FES WalkAide device and there is documented improvement as well as the patients subjective report of improvement. The patient has tried standard therapies including anti-spasticity agents with Baclofen and AFO. Further, the patient is not a candidate for treatment with Ampyra due to a higher risk of seizure as noted on an electroencephalogram (EEG). Given the patients improvement with WalkAide, the requested device is more likely to be beneficial for treatment of her medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Lyrica. The U.S. Food and Drug Administration (FDA) noted that the generic formulation of a medication is created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. The FDA continued to state that, these similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand-name version. In this case, the patient has a diagnosis of fibromyalgia, which is an FDA approved indication for Lyrica. The patient was treated with generic Lyrica, which was associated with cognitive impairment and depressed mood. The patient reported that his pain was not under adequate control with generic Lyrica. The patient state that treatment with brand name Lyrica has been more effective in managing his pain. The reported side effects from the generic Lyrica are known to occur with the brand name Lyrica and are not unique to the generic formulations. Based on the available documentation, the requested brand name Lyrica is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested brand name 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cialis for treatment of his medical condition. Findings: The physician reviewer found that Cialis is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested services. Cialis is U.S. Food and Drug Administration approved for the indication of erectile dysfunction or symptomatic benign prostatic hyperplasia. Coward and Carson report recent studies show a significant treatment benefit from once-daily, low-dose tadalafil. Given the support for the proposed medication dosage, Cialis is supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication dosage 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 urology 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 bariatric surgery for treatment of her medical condition. Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  Clinical notes do not document serious comorbid conditions such as hypertension, diabetes or sleep apnea.  The Health Plans requirement that this patient with a BMI of 36 have at least one significant obesity-related disease complication prior to approval of bariatric surgery is medically appropriate.  There is a lack of support for the requested services in this clinical setting.  All told, the requested bariatric surgery is not medically indicated for the 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 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: Overturned

The parent of a two-year-old female enrollee has requested speech therapy at the frequency of two days per week for 30 minutes per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that an extensive review of the literature including meta-analysis by Law and colleagues noted positive effects of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. The authors noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Data further suggests that approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while those who participate in speech and language therapy show better improvement than those children who are untreated. Similarly, Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment and reported statistically significant improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. Consistent with these findings, the requested speech therapy in this case is medically necessary to address this patients speech and language delays. This patient should also undergo a follow-up speech and language evaluation given that the patients initial evaluation was performed more than one year ago.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested a total disc arthroplasty and application of cranial tongs (22856) for treatment of his intractable left C5 radiculopathy attributable to new left paracentral C4-C5 disc herniation.  Findings:  Three physician reviewers found that In an assessment of the safety and efficacy of cervical disc arthroplasty, Matz and colleagues performed a systematic review of the literature. The authors examined 10 studies that reported outcomes of arthroplasty compared to preoperative function or anterior cervical discectomy with fusion (ACDF).  Matz and colleagues reported that the studies by Porchet and Metcalf (55 patients), Hacker (46 patients), and Coric and colleagues (33 patients) all reported randomized series of patients with cervical degenerative disease who underwent either arthroplasty or ACDF. These individual reports were subgroups of patients included in a larger randomized controlled trial. In these studies, both the arthroplasty and ACDF groups showed clinical improvement without significant differences between groups at 24-months postoperatively on NDI and SF-36.  However, the authors noted that these studies were graded Class II because it was not evident how randomization occurred and whether the assessments were done by blinded observers.Given the lack of Class I evidence, it cannot be concluded at this time that cervical arthroplasty is more effective than ACDF with plating for control of neck and arm pain. Also, longer term outcome studies are needed to assess whether motion is actually preserved following arthroplasty. As such, the superior efficacy of the requested procedure has not been established at this time. With regard to this particular patient, he has had previous surgery at C5-C6, and the requested procedure is contraindicated for patients with symptomatic cervical disc disease at more than one level. All told, the requested total disc arthroplasty and application of cranial tongs (22856) is not likely to be more efficacious than alternative treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400mg/100 mg and ribavirin 200 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus.Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. All patients should be treated, regardless of fibrosis stage.  Per the guidelines, in patients who have failed Sovaldi and ribavirin, treatment is recommended with Epclusa and ribavirin for 12 weeks, based on clinical studies. This applies regardless of the results of any resistance testing. Due to the patients prior severe side effects with ribavirin, this regimen is more appropriate than alternatives requiring longer duration of ribavirin treatment. Final Result: The reviewer determined that requested medication regimen 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages 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. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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.  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.