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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Botox injections (onabotulinumtoxinA), every ten weeks. Zidan and colleagues report that while the current standard protocol for onabotulinumtoxinA for the treatment of chronic migraine injections consists of fixed-site injections every 12 weeks, it is unclear if this protocol is optimal for chronic migraine as in clinical practice, migraine patients frequently describe a period of increased headache frequency and intensity in the few weeks preceding their next injections. Masters-Israilov and Robbins report that most patients with chronic migraines receiving onabotulinumtoxinA experience wear-off, most commonly occurring between two to four weeks before the next injection in cycles of 12-week injections. The authors conclude that clinicians may consider increasing the units used from the treatment onset to reduce the frequent need for bridging therapies. Allowing more frequent Botox treatments may reduce the need for bridging therapies such as nerve block injections and intramuscular injections in between Botox treatments. In this case, given that the patient has tried and failed multiple medications, including Botox on a 12-week cycle, the requested medication regimen is medically indicated. Therefore, Botox injections (onabotulinumtoxinA), every ten weeks, are 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for MyoPro Motion G (upper extremity myoelectric orthosis  CPT L8702). Findings:  The physician reviewer found that MyoPro Motion G upper extremity myoelectric orthosis has not been demonstrated to help patients with arm weakness due to a stroke to perform self-care tasks or activities of daily living better than without the device. In addition, the MyoPro Motion G device has not been shown to improve any health outcomes following a stroke, such as reducing the incidence of overuse injury of the opposite, unaffected limb. Moreover, the MyoPro Motion G is relatively heavy compared to the anatomical weight of the arm, which makes it difficult for the patient to place the affected upper extremity into positions where she can use the device in a purposeful manner (Harrison and Field). The device may also cause a patient with a hemiparetic gait to have greater instability while ambulating due to an unfavorable displacement of the center of gravity caused by wearing the device. Overall, the requested MyoPro Motion G device is not expected to provide any clinically or functionally significant marginal benefits over conventional orthotic therapy for the treatment of this patients stroke related functional deficits. For these reasons, the requested MyoPro Motion G (upper extremity myoelectric orthosis  CPT L8702) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation 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 magnetic resonance imaging (MRI) of the left elbow. The submitted documentation supports the requested services in this clinical setting. This patient has requested coverage for MRI of the left elbow, and the Health Plan noted that an ultrasound should be performed prior to MRI. This patient has indications for additional imaging given her continued symptoms despite conservative treatment. MRI is the procedure of choice in this patients case. This modality is not as dependent on operator skill, and the MRI images can depict chronic tendinosis and micro-tears of the extensor tendon. All told, MRI of the left elbow is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nutropin AQ Nuspin 5 mg/2 mL pen injector for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that growth hormone deficiency is a medical condition in which the body does not produce enough growth hormone.  Recognized effects include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance. Growth hormone replacement therapy can provide a number of measurable benefits to growth hormone deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. In patients with known hypothalamic or pituitary disease, providers can establish the diagnosis of growth hormone deficiency with high sensitivity and specificity when there are three or four additional pituitary hormonal deficiencies or a sub-normal IGF-1 level. To establish the diagnosis in patients without these criteria requires provocative growth hormone stimulation. In this case, the patient meets the criteria for growth hormone deficiency as she has a low IGF-1 level, and mounted a sub-normal response to provocative testing with glucagon. Therefore, the request for Nutropin AQ Nuspin 5 mg/2 mL pen injector is medically necessary for treatment of the patients medical condition. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of her breast cancer screening. Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  There is a family history of breast cancer in a paternal grandmother who was diagnosed.  The patient has a history of a prior benign ultrasonically guided core biopsy of the right breast. She underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views. The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Scattered benign appearing nodularity and calcifications were noted. Her breast tissue was described as dense. The patient requested reimbursement for the breast tomosynthesis portion of the examination. The Health Plan denied reimbursement as investigational for purposes of evaluating this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breast tissue was described as dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 45 mg/0.5 mL, two syringes every eight weeks.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The Health Plan has denied the request for coverage, as Stelara is most typically dosed every 12 weeks.  In this patients case, there is no documentation as to other systemic therapies that the patient has tried and failed.  Given that she has not been treated with alternative therapies at the typical dosages and schedules, the request for increased Stelara dose is not medically indicated.  It appears that this medication may not be effective for the patient in clearing her psoriasis.  Thus, alternative treatments are medically appropriate prior to increasing the dosage of this medication that has been only partially effective.  In sum, the requested Stelara 45 mg/0.5 mL, two syringes every eight weeks is not medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheldCredentials/Qualifications: Physician 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: Medical Necessity
Decision: Upheld

The patient is a 56-year-old woman who requests a bone mineral density study to determine the progress of her osteoporosis evaluated on two previous scans in February 2002 and March 2004. The second scan showed progressive loss of bone at the hip and spine in excess of what might be expected at her age. At that time she was apparently taking hormones and thyroid medications and had some recommendations according to the note from her physician. Eighteen months later, the etiology of her bone mineral density loss is unknown, and her present medications are unknown. Her physician has recommended another bone density study.The etiology of the patients bone loss is unknown. It could be due to an early menopause, now without estrogen replacement, or excessive thyroid hormone treatment, or some other cause for secondary osteoporosis. The patient should be referred to a physician who has knowledge in the diagnosis and monitoring of the treatment of osteoporosis.If, after a thorough evaluation this patient is diagnosed with post-menopausal osteoporosis and appropriate treatment is begun, there are several ways to monitor the success of the specific treatment. To monitor the progression of post-menopausal osteoporosis, a baseline bone density study and/or markers of bone turnover can be obtained and either a repeat bone density study at two years of treatment, or bone markers at six months would be appropriate. Based upon the information provided, there is no clinical indication for a bone density study at this time. Therefore, I have determined that the requested bone density study is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for intravenous Entyvio.The medical literature supports that the requested medication is medically necessary. Entyvio is supported as primary therapy for the treatment of Crohn's disease. Entyvio has shown efficacy in patients with Crohn's disease, even if there has been inadequate response to other therapies. In the GEMINI II trial, Entyvio proved efficacious for induction of remission in a randomized controlled trial of 368 patients, as well as a large cohort of 747 patients. It has also proven effective for maintenance of remission, achieving a 39% remission rate in patients who had failed prior therapies. Systematic reviews found that Entyvio is significantly more effective for inducing remission than placebo. The use of Entyvio is supported by American College of Gastroenterology guidelines in patients with Crohn's disease regardless of whether other therapies have been attempted or failed. In this case, the patient has Crohns colitis and has had unexplained neurologic symptoms (blurry vision) while on Humira, and the use of Stelara is less appropriate than Entyvio given the association of Stelara with posterior reversible encephalopathy syndrome. Entyvio, in contrast, is gut-selective and additionally does not appear to cross the blood-brain barrier. Accordingly, the requested intravenous Entyvio is medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested chiropractic services for the treatment of his chronic back pain. Findings:  The physician reviewer found that the American Chiropractic Associations Council on Chiropractic Practices and Medicare guidelines state that a treating provider is expected to keep and maintain adequate case records which clearly show the progression of care, clinical impressions, assessments of the patients condition and treatment effectiveness from visit to visit. In this case, office visits were often once per month, with no documentation as to why the patient sought care or how the patient faired with the prior treatment. The records fail to indicate progression or regression of the patients complaints, fail to indicate provocative and/or palliative conditions, and fail to indicate any reduction in pain or improvements of functional capacity of the patients musculoskeletal system. Therefore, based on the information provided, the medical necessity of the services at issue is not supported.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested IVIG treatment for the treatment of his multiple sclerosis. Findings:  The physician reviewer found that while there have been some reports that IVIG is beneficial in treating multiple sclerosis, it is not the standard of care or FDA approved for this indication. At this time, there is inadequate scientific data demonstrating that IVIG has clinical value in the treatment of patients with multiple sclerosis. As such, the use of IVIG in this clinical setting is not medically justified.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female has requested for residential treatment center services for treatment of her medical condition. Findings:  The physician reviewer found that the documentation contains no evidence that the patient was suicidal, homicidal or showing impaired reality. the facility records note that the patient did not have any suicidal, homicidal or psychotic symptoms upon admittance. In the absence of such evidence, the medical necessity for 24-hour structure, supervision, and treatment is not established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her morbid obesity. Findings:  Two physician reviewers found that the patient is seeking a laparoscopic sleeve gastrectomy. The Health Plan has denied authorization for the procedure on the basis that it is considered experimental and is not as good as or better than laparoscopic gastric band (LGB) or laparoscopic Roux-en-Y gastric bypass (LRYGBP) according to the literature. Laparoscopic sleeve gastrectomy is widely accepted in the literature as both a standalone procedure and as the first phase of a two-stage procedure (followed by duodenal switch). Recent trials and reviews of five and eight year-data clearly show that laparoscopic sleeve gastrectomy is as good as or even better than LRYGBP. In the case of this patient, she has a history of peptic ulcer disease, is on lifelong anti-coagulation therapy, and takes non-steroidal anti-inflammatory drugs (NSAIDS) which significantly increases her risk for bleeding. She had a gastric polyp removed. With LRYGBP, the gastric remnant would make future endoscopic evaluation impossible. In addition, the patients dosage deliverance and absorption of her medication is critical and with LRYGBP this will be very unpredictable because of the rapid push to the distal small bowel. Furthermore, management of the patients anemia and vitamin deficiencies would be more difficult with LRYGBP.With regard to LGB, a study by Uglioni, et al. found that that after 5 years, 39% of LGB treated patients either had their bands removed or had insufficient weight loss. Recent studies also show that longer-term weight loss is much better with sleeve gastrectomy than with LGB, and the former results in greater improvement of co-morbidities. Moreover, band erosion while on anti-coagulant therapy would be very problematic.All told, given the patients medical history and current need for medications, sleeve gastrectomy is more appropriate than any other available weight loss procedure.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has a vertical sleeve gastrectomy (gastric sleeve laparoscopic surgery) for the treatment of her morbid obesity. Findings:  The physician reviewer found that there has been much enthusiasm in the literature for vertical sleeve gastrectomy (VSG) due to early reports of good results. However, as a stand alone procedure there are no credible long-term studies that prove the weight loss will continue. Early studies reveal some patients may stop losing or even regain weight. Since the VSG operative technique has not been standardized, an article by Roa and colleagues states that there is no consensus regarding what gastric volume should be created. Many of the studies use different bougie sizes for the sleeve and different antral resection lines. Nearly all of the studies in the relevant medical literature including those referenced above indicate that long-term results are still necessary to confirm the value of VSG as a stand alone procedure. The surgical alternatives proposed by the Health Plan are medically appropriate and viable options and have greater support in the clinical literature than VSG.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee requested authorization and coverage for residential treatment services. The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old male enrollee has requested reimbursement for psychiatric acute inpatient services for treatment of the enrollees depression. Findings:  The physician reviewer found that this patient has a history of depression and suicidal ideation and was admitted for acute inpatient hospitalization through the emergency room. A review of the submitted notes reveals no documentation of the patients suicidality and his depression is not clearly outlined in the records provided. The patient was not showing any suicidal intent and did not show any plan for which he wished to carry out his suicidal ideation. Accepted psychiatric acute inpatient admission criteria indicates there must be an imminent risk of danger to others or suicidal risk to warrant an acute inpatient level of care. This is not documented in the records provided, as the patient did not appear to be in any immediate danger, such that 24-hour supervision would have been required. All told, this patient could have been treated in an intensive outpatient program or partial hospitalization program rather than an acute inpatient hospitalization program. Therefore, the medical necessity of an acute inpatient level of care has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested  for 1-on-1 dialectical behavior therapy (DBT), including one family treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the reviewed medical literature supports DBT in reducing severe dysfunctional behaviors such as parasuicide as in this patients case (Koerner and Linehan). Moreover, DBT is now being used successfully to treat adolescents who demonstrate self-injurious behaviors (Wilkinson). The DBT itself consists of two components: an individual component in which the therapist and patient discuss weekly issues recorded on diary cards, and follows a treatment target hierarchy with self-injurious and suicidal behaviors taking first priority; and a group component with meetings once per week for about two hours, learning to use specific skills that are broken down into four modules. In this case, the provider has documented the proper use of DBT according to general practice guidelines. For these reasons, the DBT provided was and continues to be medically necessary.