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

The parent of a two-year-old female enrollee has requested speech therapy once per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, this young patient has an identified delay in receptive speech and expressive speech of 55%. Speech therapy is indicated for patients who present with any delay greater than 25%. An 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 two years catch up to peers by three years of age, while children with mild to moderate disorders are most likely to resolve their delay. Moreover, the authors found that young patients treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. All told, 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. For these reasons, the requested speech therapy is medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old male enrollee has requested for a bilateral breast reduction/lump removal for treatment of his gynecomastia.  Findings:  The physician reviewer found that this patients tender gynecomastia has a clinically significant impact on his activities of daily life. Moreover, the tissue involved is glandular in nature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira pen injector. Findings:  The physician reviewer found that the American Academy of Dermatology guidelines for the management of psoriasis includes topical therapy as first-line treatment. If ultraviolet treatment is not available, other first-line treatments include acitretin, adalimumab, cyclosporine, etanercept, infliximab, methotrexate and ustekinumab. In this case, the patient has used topical clobetasol for her scalp psoriasis, but her provider described it as ineffective. The provider has recommended Humira because the patient is of childbearing potential and is considering starting a family. Humira has not been proven to be safe in pregnancy. Humira is pregnancy category B, which means that animal reproduction studies have failed to demonstrate a risk to the fetus, and there are no adequate and well-controlled studies in pregnant women. Since the patient has only been treated with topical clobetasol, and Humira has not been proven to be safe in pregnancy, the requested medication is not medically indicated. Therefore, Humira pen injector is not medically necessary for the 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 dermatology 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.Findings:  Two physician reviewers found that the medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: Two 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: 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 actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old woman with a strong family history of breast cancer. Her mother was diagnosed with breast cancer at age 46. Her paternal grandmother was diagnosed at age 48. Her maternal grandmother was diagnosed at age 80. A sister was diagnosed at age 48 and underwent bilateral mastectomies. Her oldest sister was diagnosed at age 55. The patient has had two benign breast biopsies. Her sisters have undergone BRCA testing with negative results; however, the patient indicates that her provider still believes there is a hereditary predisposition in her family. She has been on Tamoxifen as a preventive agent.  It has been recommended the patient undergo screening with MRI in addition to a mammogram. The Health Plan has denied coverage for the requested MRI on the basis that it is not medically necessary.The use of screening and diagnostic MRI of the breast is becoming increasingly used and increasingly controversial. There is little support for routine use of MRIs in screening. However, there is developing and good data that in high-risk women, particularly at a young age, MRI screening is superior to mammography. Such high-risk women include women with BRCA mutations, as well as women with family histories including two or more close relatives with breast cancer at a relatively young age. A recently published study screened 1900 high-risk women with mammography and MRI. MRI was found to be clearly superior in its ability to detect breast cancer, and demonstrated a much higher incidence of detecting smaller and node-negative cancers than mammography. In light of these results, MRI screening is medically appropriate and indicated for this high-risk patient.Based upon the information set forth above, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested real-time remote heart monitoring for evaluation of her tachycardia.  Findings:  Two physician reviewers found that the patient has well-documented symptomatic supraventricular tachycardia in the setting of a structurally normal heart by cardiac MRI and stress echocardiography.  In this circumstance, additional cardiac monitoring adds very little information.  If additional monitoring were thought to be medically necessary, then non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias.   Continuous off-line 24 to 48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently.  Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms.  In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient.  There is no documentation to indicate the patient is not able to effectively manage these standard monitoring devices and no indication that these have been previously obtained to evaluate the patients condition.  Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient-activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias.  In this patients case, remote real-time heart monitoring was not likely to be superior over other tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee requested Minivelle 0.1 mg, 24 hour patch for medical treatment of her hormone imbalance.  Findings:  The physician reviewer found that although it is reasonable for the patient to prefer a transdermal option for her estrogen therapy, Minivelle and Vivelle-Dot are essentially equivalent. The usage, delivery system, and dosing are identical. The Vivelle-Dot is square and the Minivelle is round, but they are essentially the same size dose for dose. According to UpToDates review on menopausal symptom treatment, The potency and therefore the doses of (various) estrogen preparations differ, but they differ little in efficacy. In this patients case the potency and dosing of the Vivelle-Dot is the same as Minivelle. In sum, there is insufficient rationale to prescribe Minivelle rather than Vivelle-Dot as both are applied the same way, and are available in identical doses. Therefore, the request for Minivelle 0.1 mg, 24 hour patch has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested contrast-enhanced cardiac computed tomography for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has significant coronary risk and no documented symptoms suggestive of coronary ischemia.  In this circumstance, guidelines to evaluate and manage cardiac risk are available, periodically updated and are endorsed by several national organizations.  The current guidelines do not recommend the use of contrast-enhanced cardiac computed tomography as a screening test to further assess coronary risk.  Cardiac outcomes using treatment based on coronary computed tomography scanning results have not been demonstrated to be incrementally better compared to treatment based on a combination of clinical risk profiling and standard lipid analysis using current guidelines.  All told, the requested contrast-enhanced cardiac computed tomography is not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 residential treatment services for treatment of his alcohol abuse.   The physician reviewer found that this patient does not meet criteria for residential level of care. He is cooperative with treatment, is gaining insight, has support from his girlfriend and does not present with any additional medical or significant psychological factors.  He could have safely continued treatment at a lower level of care. Accordingly, residential treatment services were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a female with bilateral leg discomfort, swelling, and weakness; left leg greater than right. Per the records, she has used compression stockings. The patient has not had a deep vein thrombosis or arterial disease. A venous duplex ultrasound showed left great saphenous vein reflux and right deep venous reflux. The patient has hyperlipidemia. The records noted an elevated triglyceride level of 575 on. She has had elevated homocysteine levels and is pre-diabetic. The patient has been treated with fenofibrate. The patient has requested coverage for Vascepa and left great saphenous vein ablation. The Health Plan denied the requests and reported the requested medication and requested services are not medically necessary for the treatment of this patient. At issue is whether Vascepa and left great saphenous vein ablation are medically necessary for the treatment of the patients medical condition. The treatment for varicose veins due to greater saphenous vein incompetence and varicosities includes ablation or removal of the axial veins and interruption of significant non-axial accessory varicosities when conservative treatment fails. Clinical trial evidence suggests that radiofrequency ablation and endovenous laser treatments are as effective as surgery in the treatment of great saphenous varicose veins and have the advantage of a shorter recovery time. The American Heart Association and National Lipid Association define very high triglyceride levels as greater than or equal to 500mg/dL. This patient has this condition. Clinical practice guidelines recommend a fibrate as the drug of first choice.  In patients with severe hypertriglyceridemia, high-dose omega-3 fatty acids or niacin be initiated along with fibrate therapy. The medical evidence supports the requested medication and requested services at issue in this clinical setting. Therefore, Vascepa and left great saphenous vein ablation are medically necessary for the treatment of this patient. 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 general surgery and vascular 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

A 63-year-old female enrollee has requested Avastin for the treatment of her metastatic lung cancer. Findings:  The physician reviewer found that Avastin has been found to be of some benefit when used in first-line chemotherapy with carboplatinum and taxol in patients with advanced non-small cell lung cancer. It has not been demonstrated to be of benefit when added to second and particularly third-line chemotherapy, as would be the situation in this case. Furthermore, its usefulness, even in first-line chemotherapy, has actually only been in patients with adenocarcinoma histology. This patient has squamous cell carcinoma. Many studies preclude the use of Avastin in patients with squamous cell histology, as discussed in the article by Sandler and colleagues. As such, there is insufficient evidence to support the use of Avastin in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female 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, although the patient engaged in self-harm in the form of cutting, she was not experiencing suicidal ideation.  She was not described as dangerous to others.  She was able to perform her activities of daily living and was not gravely disabled.  Her behavioral and emotional disorders were ongoing in nature and she was not in an acute or crisis situation. Her cutting behavior did not represent deterioration from her usual status; it was an ongoing pattern of behavior of the past few years which had not worsened. Additionally, her social environment was not characterized by temporary stressors or limitations that would undermine treatment, as the patient lived at home with parents who were supportive in nature. Moreover, the services provided to the patient during residential stay, such as individual, group and family therapy and DBT could have been provided at a lower level of care. Changes in the patients medication regimen were not of a complex nature that it required 24-hour supervision on an inpatient setting. She was not psychiatrically compromised such that she would have required 24-hour supervision on an inpatient setting. Given the above, the patient did not meet criteria for residential level of care. She could have been treated safely at a lower level of care; therefore the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repeat treatment of Harvoni for 12 weeks with ribavirin for treatment of the enrollees medical condition. Findings:  The physician reviewers found that according to the 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The AASLD and IDSA guidelines do not specify a course of action for genotype 4 patients who have failed Harvoni. For genotype 1 patients who have failed Harvoni, and are without NS5A resistance, Harvoni and ribavirin for 24 weeks is recommended.Final Result: Two of three reviewers determined that the requested medication 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. Credentials/Qualifications: Physician reviewers number one, two, three 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prolotherapy (CPT code 0232T) in the left knee. There is a paucity of medical literature supporting the long-term safety and efficacy of platelet-rich plasma for treatment of knee pain. In addition to transient side effects such as post-injection swelling and pain, short duration nausea and dizziness, the incidence of side effects appears to be more common with multiple injection protocols. Short-term benefits, lasting from six months to over one year, have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. Filardo and colleagues performed a randomized controlled trial comparing platelet-rich plasma injections to hyaluronic acid injections in a 192 patients with 12-month follow-up. The authors reported significantly more post-injection swelling and pain in the platelet-rich plasma group with no significant differences in outcome. The authors concluded that platelet-rich plasma should not be preferred to viscosupplementation. This patient underwent prolotherapy with platelet-rich plasma injections on two occasions for symptomatic right knee osteoarthritis. Based on the peer-reviewed medical literature, platelet-rich plasma injections are not recommended for the treatment knee osteoarthritis over standard therapies. All told, the prolotherapy (CPT code 0232T) in the left knee was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the prolotherapy (CPT code 0232T) in the left knee was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 in orthopedic surgery 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.