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

The patient is a 54-year-old female with end stage renal disease (ESRD) who is a candidate for renal transplant. The patients sister does not share the patients blood group but is willing to donate a kidney to the patient so that the patient may obtain a living donor kidney transplant. The patient is seeking authorization for an incompatible living donor kidney transplant. The Health Plan has denied this request.Current literature clearly indicates that all types of renal transplant are superior to dialysis. In addition, living donor transplants are superior to cadaveric transplants. Furthermore, given current modes of immunosuppression, a living incompatible transplant will most likely have superior results to a cadaveric transplant. A renal transplant is the most clinically appropriate and medically indicated procedure for this patient. The proposed living incompatible donor transplant will be more beneficial and is more appropriate than continuing the patient on dialysis. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a four-year-old female enrollee has for continued occupational therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that autism is a disorder of communication, socialization and behavior. It is usually addressed by an interdisciplinary team focusing on psychoeducational issues. There are no specific medical treatments for autism.  Occupational therapy is not considered clinically indicated for treatment of patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography scan (CAT) for evaluation of the enrollee who has a history of hyperlipidemia. Findings: The physician reviewers found that while the research in coronary CAT for calcium scoring has advanced over last few years, it has not been proven with any long term study or trial that it is better in predicting adverse outcome when compared with other ways of risk stratification and therefore, it is still considered to be investigational. Cardiac CAT scan for calcium scoring is a well-established method for detecting atherosclerotic calcification involving coronary arteries. It has been established that the coronary calcium burden is related to adverse outcome. However, what continues to be the matter of debate is how it can predict outcome when compared with other laboratory and non-laboratory data. There are several different ways to stratify risk for coronary events including patients symptoms, risk factors, lifestyle, and laboratory data. There is lack of research comparing calcium scoring CAT against other factors that can stratify risk because this type of comparison is difficult to perform between these variables. In 2009, the United States Preventive Services Task Force (USPSTF) issued recommendations on using nontraditional risk factors in coronary heart disease risk assessment. The USPSTF concluded that the evidence is insufficient to assess the balance of benefits when using this modality. They determined that the evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. As such, USPSTF recommended against screening asymptomatic men and women with no history of coronary heart disease. In sum, CAT scan will not likely be more beneficial than other standard methods of assessing coronary disease in this patient.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: 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 guardian of a 13-year-old female enrollee requested 60-day psychiatric residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient has a significant family history of mental illness and a profoundly debilitating affective symptom complex, cast with impulsivity, aggression and psychosis, which is impairing multiple domains of functionality. In accordance with modern psychiatric practice, the patient has pursued treatment in less restrictive settings. She failed the outpatient and partial hospital levels of care and has had multiple acute psychiatric hospitalizations. As such, a conservative course of care is to be expected. According to the medical records, the patient is engaged in active treatment including but not limited to pharmacotherapy, psychological assessment, family therapy, nursing services and individual therapy. The services are in part for purposes of diagnosis, as autism spectrum disorder is being considered.  Considering the factors specific to this case and typical community practice standards, it would be medically reasonable and appropriate to forecast a 60-day treatment course at the residential level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left knee replacement and right knee replacement. In their multicenter longitudinal cohort study, Riddle and colleagues concluded that the risk-to-benefit ratio for total knee arthroplasty (TKA) is best for patients who have intense or severe symptoms of knee osteoarthritis, are at least 55 years old, have limited mobility, and a BMI less than 40. The authors found that surgical outcomes are less favorable for patients who have mild or moderate symptoms. Medical literature shows a national cohort sample study of 2,040 hip and 2,964 knee replacements evaluating pain and function according to BMI status. Within this sample, 14% of hip and 25% of knee patients were severely or morbidly obese. Six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity is not a deterrent to undergoing total joint replacement to relieve symptoms. Another group reported similar findings. This patient presents with progressive worsening bilateral knee pain. The records document that the patients pain is severe and interfering with his ability to perform activities of daily living. Clinical examination findings are consistent with radiographic evidence of severe bilateral knee osteoarthritis. The records include detailed evidence of long-term non-operative treatment without sustained improvement. His BMI is elevated at 41.87. There is documented weight loss since 2017. He meet the other evidence based medical criteria for TKA. Current medical literature supports proceeding with TKA in the setting of the patients current BMI. Therefore, the requested right knee replacement and left knee replacement are medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Mavyret 100 mg - 40 mg tablets for the duration of eight weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that The physician reviewer found according to the most recent 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1b patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Mavyret 100 mg - 40 mg tablets for the duration of eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee makoplasty. The Health Plan has denied this request indicating that the requested services are investigational for the treatment of the enrollees left knee pain.Findings:  Nationally recognized evidence based medical guidelines do not recommend makoplasty knee arthroplasty based on lack of evidence showing improved clinical outcomes. Further research is needed to determine if this technological advancement will translate into improvements in longevity and clinical outcomes. At present, few studies have assessed and compared the survivorship and functional outcomes of robotic-assisted surgery to conventional knee arthroplasty. This patient presents with persistent left knee pain. Records documented conservative treatment to include corticosteroid injections, activity modification, and medications, without sustained improvement. Clinical examination findings have documented medial joint line tenderness, varus alignment, and pseudolaxity on varus/valgus stress. There is radiographic evidence of bone-on-bone articulation with periarticular osteophytes to the medial compartment, moderate to severe degenerative changes to the patellofemoral compartment, and mild to the lateral compartment. The patient has been recommended for a bicompartmental knee replacement using the makoplasty system. However, current evidence based medical guidelines and peer-reviewed literature do not support the use of robotic assisted surgery over conventional knee replacement based on lack of evidence for improved outcomes. As such, a left knee makoplasty is not likely to be more effective for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined 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:  All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

A 40-year-old male enrollee has requested lipoprotein-associated phospholipase A2 (Lp-PLA2) testing for an evaluation of his risk of cardiovascular disease. Findings:  Three physician reviewers found that the patient is a 40-year-old male who is requesting lipoprotein-associated phospholipase A2 (Lp-PLA2). Overall, there is no evidence that this test is helpful in changing clinical outcomes.  In addition, at the present time, there is limited literature to support its efficacy. Furthermore, the test at issue is not supported by the American College of Cardiology (ACC) Guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee requested cardiac event monitoring services for treatment of his arrhythmia.  Findings:  Two physician reviewers found that the cardiac event monitoring  was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The studies published to date have not shown improved patient outcomes using cardiac event monitoring technology. At this time, there are insufficient randomized studies involving large numbers of patient that show immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services results in improved health outcome compared to standard monitoring techniques. Based upon the information set forth, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old male, with dyspnea on exertion, has requested authorization for CT angiography (CTA).Reviewers' Findings:Two out of the three reviewing physicians found that a CTA is appropriate for a symptomatic patient when there is an uninterpretable or equivocal stress test. In this instance, dyspnea on exertion can be considered an anginal equivalent and the patients stress test was consistent with an equivocal interpretation; thus establishing a valid basis for the application of CTA.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology (ACR) appropriateness criteria for the evaluation of low back pain note that most patients presenting with uncomplicated acute low back pain or radiculopathy do not require imaging. Established criteria for chronic neck and low back pain note that MRI is generally not appropriate in the management of chronic pain absent other red flags, such as persistent symptoms following four to six weeks of conservative management, a suspicion of serious underlying conditions, or if the patient is a surgical or interventional candidate. In this case, while the patient reports chronic back pain, the documents do not reflect evidence of radiculopathy, numbness, loss of reflexes, or weakness. The records indicate that the patient received physical therapy in 2018. Per the submitted documentation, he received conservative therapy in the remote past. The documents do not show recent attempts at conservative management, such as physical therapy. While MRI may be appropriate following documented recent conservative treatment, it is not currently medically indicated. Therefore, MRI of the lumbar spine is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 diagnostic radiology 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

The parents of a 3-year-old male enrollee requested authorization and coverage of vision therapy for the treatment of esotropia.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that vision therapy is not likely to be more beneficial for treatment of the enrollees esotropia than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested coronary computed tomography angiography for evaluation of himself, who has a history of neck pain and an abnormal electrocardiogram. Findings:  Three physician reviewers found that the services at issue were likely to have been of greater benefit than other methods of evaluation.  This patient had significant coronary risk and ongoing atypical chest discomfort in association with prior unremarkable stress testing.  In this clinical setting, additional cardiac evaluation was indicated.  Current guidelines endorsed by several national organizations consider coronary computed tomography scanning to be medically appropriate in patients with continued symptoms and prior normal exercise stress testing.  The current medical evidence supports the superior efficacy of coronary computed tomography angiography for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee requested authorization and coverage of radiofrequency ablation of cervical facets for the treatment of cervogenic headaches.  The health plan denied the enrollees request indicating that the long-term efficacy of the requested procedure has not been established; therefore, the requested procedure is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical review.  Each of the three physician reviewers concluded that radiofrequency ablation is not likely to be more beneficial for treatment of the enrollees cervogenic headaches than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 9-year-old female enrollee has requested custom foot orthotics for treatment of the enrollees pronation deformity of foot. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The documentation submitted for review does not demonstrate that the patient has tried and failed conservative therapy consisting of strapping and over-the-counter arch supports. Pronation is a triplane deformity consisting of abduction, eversion, and dorsi flexion. The peer-reviewed literature indicates that control of the pronation helps with associated symptoms. According to Nesbitt, Foot pronation-inward tilting of the ankles and flattening of the arches is a normal part of walking and running. But when it's excessive, it can lead to foot, ankle, or even knee pain. Properly designed shoe inserts, called orthoses, can help correct overpronation. Given that the patient has not failed conservative treatment options consisting of strapping and over-the-counter orthotic therapy, the requested equipment is not clinically indicated at this time. As such, the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys sublingual spray for treatment of her rheumatoid arthritis.  The physician reviewer found that according to the current evidence-based literature, Subsys sublingual spray is used for the management of breakthrough cancer pain in opioid tolerant patients. The clinical records submitted for review indicate that this patient has been utilizing the medication due to pain from rheumatoid arthritis. The clinical records submitted for review showed no indication that the patient has any form of cancer pain. Therefore, the requested Subsys sublingual spray is not recommended to treat this patients condition. As such, the requested medication, Subsys sublingual spray, is not medically necessary for treatment of the patients rheumatoid arthritis. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton therapy for treatment of the enrollees recurrent left breast cancer. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Small studies have demonstrated the ability of proton therapy to reduce lung and cardiac for left-sided breast cancer dose exposure, however it is not clear if such reductions are clinically meaningful for proton therapy to be recommended for general use (MacDonald, et al; Ares, et al). Many other technologies also allow for reduction in normal tissue dosing, including intensity modulated radiation therapy (IMRT). Although the breast is in close proximity to the heart and lungs, it is not evident that proton therapy is needed to sufficiently reduce lung dose-volume exposure in this patients case. The records submitted do not include a dosimetric rationale which demonstrates the insufficiency of three-dimensional (3D) conformal or IMRT. Moreover, proton therapy for breast cancer is not an accepted standard of care. For the reasons provided, the request for proton therapy has not been established as medically necessary for the treatment of the patients breast cancer. 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 radiation oncology 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.