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

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for the medication Nutropin AQ Nuspin. The Health Plan has denied this medication indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. At issue in this case is whether the requested medication Nutropin AQ Nuspin is medically necessary for treatment of the enrollees medical condition.Researchers suggest that growth hormone treatment be offered to individuals with persistent growth hormone deficiency in the transition period. There is evidence of benefit; however, the specifics of the patient population that benefits, the optimal time to re-initiate treatment and the optimal dose are not clear. Based on the criteria by policy, the request is approved if patient is compliant with the medication, has a growth velocity of more than 3 cm per year, and there are no side effects. The patient meets these criteria. This is a request for continuation of treatment with growth hormone after one year of treatment. Therefore, this patient meets the criteria for continuation of treatment with growth hormone and the medication Nutropin AQ Nuspin is medically necessary.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 pediatrics with a subspecialty certification in pediatric endocrinology 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
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for a RT300 Functional Neuromuscular Electrical Stimulation device provided by Restorative Therapies, Inc. Murphy and colleagues describe acute flaccid myelitis (AFM) as a disabling, polio-like illness mainly affecting children, and that the disease appears to be caused by non-polio enterovirus infection. The authors note that following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs and that patients engaged in multimodal rehabilitation can achieve functional improvements for years even after recovery of motor strength plateaus. Melicosta and colleagues report in a retrospective chart review of 31 patients with AFM who underwent activity-based restorative therapy (ABRT), including functional electrical stimulation (FES), that children with flaccid paralysis due to AFM undergoing structured, comprehensive rehabilitation interventions, even when these are initiated long after paralysis onset, can make significant neurologic and functional gains. The authors further noted that recovery of function and prevention of comorbidities are the main therapeutic targets for interventions in this population. Sadowsky and colleagues prospectively followed 25 patients with chronic spinal cord injury (SCI) who received FES during cycling and reported that FES was associated with an 80% change in neurological function: motor, sensory, and combined motor-sensory scores compared to 40% in controls. In this case, the patient has residual right arm weakness due to acute flaccid myelitis. In this clinical setting, the requested device is medically indicated. Therefore, the RT300 Functional Neuromuscular Electrical Stimulation device provided by Restorative Therapies, Inc. was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 51-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for the treatment of fibroids.  The health plan denied the enrollees request indicating that UAE is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that UAE is not likely to be more beneficial for the treatment of the enrollees fibroids 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 treatment, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested eye movement desensitization and reprocessing therapy for treatment of the enrollees post-traumatic stress disorder (PTSD) and pain disorder. Findings: The physician reviewer found that there is a lack of evidence to show that this patient had objective functional improvement from the eye movement desensitization and reprocessing (EMDR) versus cognitive behavioral therapy (CBT). At the time that she underwent EMDR, she was attending multiple group therapies and she was in individual therapy. In addition, the patients symptoms are not well delineated in the records provided for review. Some of the classic symptoms of post-traumatic stress disorder (PTSD) include hypervigilance, nightmares, and flashbacks, none of which are described in notes provided for review. Rather, she reports depression, anxiety, and anger. Based on these findings, there is a lack of medical necessity for the requested EMDR twice per week for treatment of this patients medical condition.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 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: Upheld

The parent of a 15-year-old male enrollee has requested the use of an ultrasound bone growth stimulator for the treatment of the enrollees left calcaneal stress fracture. Findings:  Three physician reviewers found that the literature fails to support the use of bone stimulators for the treatment of stress fractures. Rue and colleagues studied the use of bone stimulators with tibial stress fractures and found no benefit. The use of the ultrasound bone growth stimulator was not medically warranted for treatment of this patients stress fracture.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (gene expression profiling), Decision Dx-UM for evaluation of his uveal melanoma.  Findings:  Three physician reviewers found that The gene test (gene expression profiling), Decision Dx-UM performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cytogenetic testing of choroidal melanoma is an established method of laboratory evaluation of melanomas. The medical literature supports the routine use of this test for patients with uveal melanoma. The testing at issue allows for adjustment of the patients monitoring and surveillance based on the genetic profile of the tumor. In addition, the counseling and eligibility for clinical treatment trials is based heavily on the tumor genetic profile. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  All three reviewers determined that the testing 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: Three physician reviewers are board certified in ophthalmology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block injection for treatment of her chronic migraine. Findings:  Three physician reviewers found that the request for occipital nerve block injection is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a diagnosis of chronic migraine and occipital neuralgia. Based on a review of the medical record, the patients conditions may be exacerbated as a result of the occipital neuralgia. The use of nerve blocks for the treatment of occipital neuralgia is well established and is known to be an effective method of treatment of the condition. Furthermore, the treatment of this condition may result in the improvement in the patients chronic migraines as occipital neuralgia is known to be secondary cause for exacerbation of migraines. Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in neurology and is 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 DecisionDx-Melanoma genetic testing (CPT 81599). The records document that this patient has a diagnosis of melanoma. According to the National Comprehensive Cancer Network (NCCN) guidelines, a melanoma with Breslow depth of 0.8 mm is clinically stage 1B. Treatment includes possible sentinel lymph node biopsy and wide local excision. Histopathology demonstrated features that could be consistent with metastatic disease.  The patients provider recommended the DecisionDx-Melanoma assay to estimate his risk of recurrence. Based on the results the patient has the lowest risk of recurrence at five years. In the medical literature, Swetter and colleagues noted that routine molecular testing including the DecisionDx-Melanoma is discouraged until better use criteria are defined. Current data support standard staging procedures such as sentinel lymph node biopsy in this clinical setting. Accordingly, the DecisionDx-Melanoma genetic testing (CPT 81599) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma genetic testing (CPT 81599) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for alprazolam 2 mg. The newly synthesized benzodiazepine class of medication effectively supplanted barbiturates as the mainstay of psychopharmacologic treatment of anxiety.  Findings:  The physician reviewer found that Although safer than their predecessor, the benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common, while a connection with Alzheimers disease later in life has been suggested in the peer-reviewed literature.  Additionally, there is growing concern of misuse, tolerance and dependence issues with this medication class. Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. These basic pharmacokinetic and pharmacodynamic properties make alprazolam a particularly addictive benzodiazepine. Contemporary practice standards aim to minimize benzodiazepine therapy and optimize treatment alternatives, particularly in patients with history of addictive illness. The submitted documentation fails to demonstrate the medical necessity of the requested medication. In terms of medication alternatives, the patient has been prescribed a longer-acting, less addictive benzodiazepine which is a safe, appropriate, standard practice intervention. Further, with a fairly conservative dose of sertraline and many other medications to choose from, he has not failed an adequate trial of pro-serotonergic medicines, which represent first-line interventions for generalized anxiety disorder and major depressive disorder. Additionally, it does not appear that the patient has pursued trusted non-pharmacologic interventions, such as chemical dependency counseling, psychodynamic psychotherapy or cognitive behavioral therapy for anxiety and/or depression. Based on the documentation provided, the patient has not exhausted evidence-based medication options or non-pharmacologic treatment alternatives to address his depression and anxiety, while the requested medication carries an unfavorable risk-benefit profile. Thus, alprazolam 2 mg 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested  intravenous immunoglobulin (IVIG) replacement therapy for treatment of the enrollees common variable immunodeficiency (CVID).  Findings: The physician reviewer found that, in this case, the patients presentation is not consistent with hypogammaglobulinemia or CVID, only IgG subclass deficiency with a normal total IgG and a slightly low IgA and asthma. Although the records refer to recurrent infections, there is a lack of supporting documentation such as chest x-ray, computed tomography (CT) chest scans, or CT sinus scans to confirm this. In addition, the patients laboratory tests do not substantiate a history of recurrent severe sinopulmonary infections or other opportunistic infections seen with a primary antibody deficiency (Bonilla, et al). The records provided do not clearly evaluate the patients ability to respond to infections as required for the diagnosis of CVID (Ballow). The patient is reported to have a low diphtheria titer, but it is unclear if she has been revaccinated to test her immune response to protein. There is also no documentation of a trial of prophylactic antibiotics or other therapies tried and failed such as aggressive allergic rhinitis treatment or vaccination with conjugate pneumococcal vaccine. The diagnosis of CVID requires a significantly reduced total serum concentrations of IgG, low IgA and/or immunoglobulin M (IgM), poor or absent response to immunization and exclusion of other immunodeficiency states or causes. In this case, the patient is reported to have low IgG subclasses and IgA but normal total IgG and IgM, but none of the other criteria of CVID (Chapel, et al). Further, the treatment of subclass deficiency with a normal total IgG with replacement IVIG remains controversial. Most experts recommend treatment which includes immunization with conjugated pneumococcal vaccine, aggressive treatment of other conditions predisposing to recurrent sinopulmonary infections, appropriate antibiotic therapy for infections, and prophylactic antibiotics. Given these findings, the request for IVIG replacement therapy is not medically necessary for treatment of this patients medical condition.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 internal medicine with sub-specialty certification in rheumatology and allergy and immunology 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

A 63-year-old male enrollee has requested cryoablation for treatment of his mesothelioma.  Findings:  The physician reviewer found that although there is some data demonstrating the benefit of the CT-guided percutaneous cryoablation for recurrent mesothelioma, these are only retrospective case series and the results of this procedure have not been proven to be superior to other medical treatments. The records indicate the patient is a candidate for standard medical therapy with radiotherapy or chemotherapy. The requested cryotherapy procedure is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage to participate in a clinical trial for a total disc replacement for the treatment of excruciating pain due to disc degeneration between L4 and L5 of the spine.  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 to participate in a clinical trial for a total disc replacement is not likely to be more beneficial for treatment of the enrollees excruciating pain due to disc degeneration between L4 and L5 of the spine 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: Overturned

A 39-year-old female enrollee has requested for an amniocentesis, ultrasound, fetal and maternal evaluation and office consultation with a perinatologist for treatment of her pregnancy. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology (ACOG) guidelines indicate that counseling regarding the risks of fetal aneuploidy and the risks and benefits for available screening and diagnostic tests should be offered to this patient. While amniocentesis is not performed prior to 15 weeks gestation, there is no reason to delay counseling until then. Both screening tests (first trimester screening) and diagnostic tests (chorionic villus sampling) are performed earlier (11 to 13 weeks gestation). Delaying the consultation until 14 to 16 weeks gestation would cause this patient to miss the opportunity to pursue these options. In addition, the National Society of Genetic Counselors recommends that counseling for the risk of aneuploidy and screening be performed as early as possible once pregnancy is confirmed. Finally, the patient has a clear diagnosis of hypothyroidism, a medical complication known to cause fetal effects if not adequately treated.