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

A 30-year-old female enrollee has requested a bone density scan for treatment of her lumbar disc disorder. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. According to the International Society for Clinical Densitometry, for post-menopausal women younger than age 65 a bone density test is indicated if they have a risk factor for low bone mass such as, low body weight, prior fracture, high risk medication use and disease or condition associated with bone loss. In this case, the patient does not meet the criteria for the requested service. The patient is a 30-year-old female with no risk factors for osteoporosis. She has not had any fragility fractures, has not been on dosage equivalent of steroids daily for three months and there is no evidence of osteopenia. In addition, the patient has no hematopoietic disease, has not been immobilized and does not have conditions which are common factors for bone mineral density testing. In sum, the patient does not meet medical necessity criteria for bone mineral density testing. Thus, the requested service is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old male enrollee requested stereotactic body radiation therapy for medical treatment of his prostate cancer.  Findings:  Three physician reviewers found that stereotactic body radiotherapy is likely to be equivalent, but not more beneficial than standard treatment consisting of conventionally fractionated radiation therapy.  At this time, there is a lack of randomized phase III trials comparing the two modalities, although studies are underway.  The available studies suggest possible equivalence between the two treatments.  In sum, the requested stereotactic body radiation therapy is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old male with previously diagnosed ADHD who is afflicted with inattention to detail, procrastination, inefficiency in planning and completing tasks, frequently misplacing items, and distractibility due to thoughts and movement in the peripheral vision. He also noted longstanding low self-esteem, excessive feelings of guilt, and negative feelings about the future. Finally, he noted a tendency to ruminate as well as suffer periods of extreme irritability, snap reactions, and subsequent depression along with hypersensitivity to perceived criticism.  At the time of the SPECT scans, he was taking Adderall 30 mg and Paxil 20 mg. His formal psychiatric evaluation identified a mood disorder with characteristic emotional swings from depression to irritability possibly that of a dysphoric mania type, diagnosed as mood disorder NOS. He was also felt to have a coexisting attention deficit disorder. Recommended treatments included Lamictal, Strattera and Lexapro.  The patient requested reimbursement for the SPECT scans performed which the Health Plan denied based upon a determination that the diagnostic procedures were not medically necessary.There is nothing about the patients history or clinical exam that is in any way enigmatic. Based on his symptoms, one could well consider him to be suffering from a bipolar-spectrum disorder as well as possible comorbid ADHD. Treatments for either of these disorders would thereby follow very standard guidelines. A SPECT scan in this setting does not add clinical value. Therefore, I have determined the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested hydrocodone/acetaminophen for the treatment of his neck and back pain. Findings:  The physician reviewer found that it is possible to achieve pain control for chronic spine pain with long-acting opioids such as Kadian, without the need for breakthrough (short-acting) opioids such as Vicodin/Norco. Devulder and colleagues reported that long-acting opioids have a pharmokinetic profile resulting in more sustained and stable plasma opioid concentration compared to short-acting Vicodin/Norco. It is this pharmokinetic profile of long-acting opioids that improves adherence to the therapeutic schedule and prevents rebound pain. In addition, the use of short-acting opioids for chronic pain increases the risk for opioid tolerance and dependence. The development of opioid tolerance may cause a patient to take more medication than prescribed, in an attempt to treat their pain. This practice, in turn, may lead to opioid dependence. One study reported that prescribing short-acting opioids for chronic recurrent pain may put the patient at risk for both under treatment, and drug tolerance (Hermos). An article by Rauck reviewed 12 chronic pain studies that compared short-acting opioids and long-acting opioids head-to-head. His review found that many patients receiving long-acting opioids showed improved treatment responses and better perception of quality of life over patients receiving short-acting opioids. In addition, the group of patients receiving long-acting opioids had better focus on daily activities, rather than on their pain, thereby improving therapy adherence and reducing pain related activities.
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: Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The addition of breast tomosynthesis to screening mammography has gained popularity due to an associated decrease in callbacks and increase in detection of small cancers.  This improvement is due to the tomographic nature of tomosynthesis which allows separation of overlying glandular tissue from underlying mass or architectural distortion.  Thus, the addition of breast tomosynthesis was likely to be of greater benefit to the patient than two-dimensional mammography without tomosynthesis. Final Result: Two 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: 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested for testosterone enanthate for treatment of the enrollees primary hypogonadism. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient requires testosterone replacement for his primary hypogonadism.  Testosterone replacement is the treatment of choice, unless contraindicated.  In this patients case, the Health Plan has denied coverage for testosterone enanthate.  However, the Health Plan will cover testosterone cypionate as an alternative.  Testosterone enanthate is equivalent to testosterone cypionate. The Health Plans requirement that the patient try the alternative testosterone cypionate is medically appropriate.  There is a lack of data supporting testosterone enanthate as opposed to testosterone cypionate in this case.  Therefore, the requested testosterone enanthate is not medically indicated 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 parent of the patient has requested authorization and coverage for speech therapy services. The submitted documentation supports the medical necessity of the requested services. Speech therapy is standard of care for children with autism spectrum disorder. Hyman and colleagues stated, All children with autism spectrum disorder (ASD) should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with ASD. Researchers noted the importance of early intervention for children with autism spectrum disorder. Studies concluded that behavioral interventions were evidence based to induce speech among individuals with developmental disabilities. Scientists described treatment for autism spectrum disorder involving intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. In this case, although the patients progress is slow, he continues to make progress. His providers recommend that speech therapy be continued. Therefore, speech therapy services 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 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: Upheld

A 62-year-old male enrollee has requested a virtual colonoscopy for colorectal cancer screening for an evaluation of his colon. Findings:  Three physician reviewers found that colonoscopy and barium enema are the first and second-line procedures used to screen for colorectal cancer. There is no record that either of these procedures has been attempted or is contraindicated for the patient. It does not appear VC would be utilized to follow-up on abnormal findings from an earlier study. Thus, the use of VC in this setting does not represent the most appropriate diagnostic procedure for the patient. VC is neither the standard of care nor the community standard for cancer screening.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested intensity modulated radiation therapy for treatment of her metastatic breast cancer. Findings:  Two physician reviewers found that there is a not a body of literature examining the use of intensity modulated radiation therapy for pancreatic metastases, since these are relatively uncommon. Intensity modulated radiation therapy is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution and minimize the dose to normal structures. Therefore, the literature for pancreatic cancer is relevant since the treatment would be similar. For this patient, radiation is indicated, given the growth and invasion of the tumor.  In this case, the treating physician is concerned about the expected kidney toxicity.  The kidneys are exquisitely sensitive to radiation, with renal damage occurring with doses in excess of 20 Gy. According to the said date, intensity modulated radiation therapy dose prescription sheet, the plan is to treat the tumor to a dose of 65 Gy. In order to prescribe this dose and maintain normal tissue dose constraints, the use of intensity modulated radiation therapy is required. Without intensity modulated radiation therapy, the prescribed dose would likely be sub-therapeutic. If this tumor progresses, it is likely to cause severe abdominal symptoms from biliary obstruction as well as abdominal pain. Intensity modulated radiation therapy is appropriate and indicated in this setting to prescribe the maximal effective dose, while maintaining normal tissue (bowel, kidney and cord) constraints.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old male has requested coverage for past anesthesia services provided during an esophagogastroduodenoscopy. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  The American Society of Anesthesiologists notes that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication, with or without analgesia, to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation,The American Society of Anesthesiologists indicates that complex procedures and procedures in high-risk patients may justify the use of an anesthesiologist/anesthetist to provide conscious and/or deep sedation.  Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of or anticipated intolerance to standard sedatives.  Additionally, patients who are 12 years of age or younger, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may require monitored anesthesia care.General anesthesia is indicated to provide sedation and analgesia for routine gastrointestinal endoscopy procedures in patients with potential for difficult intubation and/or ventilation with a mask, and patients at risk for airway obstruction, such as patients with a diagnosis of clinically significant sleep apnea.  In this patients case, he has significant sleep apnea.  In addition, he has comorbidities of hypertension and obesity.  The use of general anesthesia was medically appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that the position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. A report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. Moreover, post-hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have a viral load of less than 6,000,000 IU/mL can be treated with an eight week course instead of 12 weeks and achieve similar cure rates. Harvoni is medically necessary based on national guidelines. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

This patient is a 63-year-old male on chronic anticoagulation therapy for atrial fibrillation. This condition requires periodic PT/INR monitoring. The patient has requested non-Plan INR testing using a fingerstick procedure; something not routinely available in the Health Plans laboratory. The patient has expressed concern that routine venipuncture will compromise his veins. The Health Plan denied the patients request for authorization of laboratory testing with the HemoSense system at a non-Plan laboratory, citing a lack of medical necessity.A review of the literature found no studies related to the long term outcome of venipuncture for patient with on-going laboratory testing. However, long term warfarin therapy has not been associated with venous compromise. There is continuing controversy about the value of fingerstick procedures, and some equipment manufacturers have submitted data demonstrating acceptable results. Nonetheless, venipuncture remains the standard for INR testing. As such, I have determined the requested services are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested Orthovisc injection to the left knee for treatment of her degenerative joint disease of the left knee. Findings:  The physician reviewer found that review of the submitted clinical information demonstrates the medical necessity of Orthovisc injections (viscosupplementation) for this patients left knee arthritis. This treatment is specifically indicated for the patient in this case given that she is at risk from gastrointestinal complications of non-steroidal anti-inflammatory drug (NSAID) use with a prior history of ileocolectomy. Recent treatment records indicate the last injections to the left knee occurred two years ago and were followed by documented clinical improvement from the initial course of injection. For these patient specific reasons, it is considered to be medically necessary for this patient to receive the recommended Orthovisc injection. This decision is consistent with a Cochrane review performed by Bellamy and colleagues in 2006 which documents the efficacy of viscosupplementation in this setting. The authors reviewed 76 trials and concluded that viscosupplementation was useful in the treatment of knee osteoarthritis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for occupational therapy and speech therapy for treatment of the enrollees developmental delays. Findings:  The physician reviewer found that as noted by Volkmar, most children with the type of deficits documented in this patient will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Volkmar noted that early intervention focused on communication and social skills can result in significant improvement. The sooner and more aggressively these deficits are targeted, the better chance the patient has for improving his functional skills. Deficits in fine and gross motor skills and sensory integration dysfunction may lead to difficulties establishing relationships, navigating the educational system, and ultimately, navigating the work force.  With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in patients such as this patient. In this patients case, a formal diagnosis of autism spectrum disorder has been deferred at present. However, this does not negate the medical necessity of intervention for this patient. He exhibits significant deficits in expressive and receptive language, as well as pragmatics.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested calcitonin, salmon, synthetic 200/spray/pump (Miacalcin) medication for treatment of the enrollees severe hypercalcemia. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the medication at issue. Calcitonin has limited efficacy for hypercalcemia. Treatment with calcitonin results in tachyphylaxis. Thus, the long-term impact is limited beyond the first 48 hours. Calcitonin may be utilized with hydration of bisphosphonates for a few days. Therefore, in this clinical setting, other treatments options for the patients hypercalcemia should be considered. All told, calcitonin, salmon, synthetic 200/spray/pump (Miacalcin) medication obtained was not and is not medically necessary for treatment of the patients hypercalcemia.Final Result: The reviewer determined that the medication at issue was not and 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 endocrinology, diabetes and metabolism 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.