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

A 25-year-old male enrollee has requested reimbursement for Chemical Dependency Residential Treatment Care (CDRTC) for the treatment of his condition. Findings:  The physician reviewer found that the patient is a chronic and persistent polysubstance abuser who uses and abuses whatever substances are available. Having experienced frequent early abuse of substances and failing outpatient care, this patient represents the classic case for which residential care is the last resort of choice. His particular traits mandated a structured setting to contain his impulsive drug use. The patient entered the RTC essentially out of control and he received appropriate care and supervision which was medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Invokana for treatment of her type 2 diabetes.  Findings:  The physician reviewer found that Sodium-glucose co-transporter-2 (SGLT-2) inhibitors belong to the American Diabetes Association algorithm in the treatment of patients with uncontrolled diabetes mellitus type 2. Jardiance has an additional U.S. Food and Drug Administration (FDA) approved indication that places it in advantage over Invokana. Jardiance reduces the risk of cardiovascular mortality in adults with type 2 diabetes and cardiovascular disease based on the EMPA-REG OUTCOME study. This study showed that over a median follow-up of 3.1 years, treatment with Jardiance reduced the composite outcome of myocardial infarction, stroke, and cardiovascular death by 14% and cardiovascular death by 38%. Whether other SGLT-2 inhibitors will have the same effect in high-risk patients or other SGLT-2 inhibitors will have a similar effect in lower-risk patients with diabetes remains unknown. Therefore, Invokana is not medically necessary as the Health Plans formulary SGLT-2 inhibitor Jardiance has the additional advantage of decreasing cardiovascular mortality. 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: Physician 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 authorization and coverage for Factor V Leiden genetic testing. Thrombophilias are hereditary or acquired conditions which can increase the risk of venous or arterial thrombosis (Stevens, et al.). As the etiology of thrombosis is multifactorial, the presence of a thrombophilic defect is only one of many elements that determine a patients risk. Factors associated with an inherited thrombophilia include venous thrombotic event at a young age, a strong family history, venous thrombotic event in conjunction with weak provoking factors at a young age, recurrent venous thrombotic event, and venous thrombotic event in an unusual site. Most guidelines recommend testing for an inheritable thrombophilia and antiphospholipid syndrome when concerning factors are present since the patients are at high risk for inherited thrombophilia conditions (Arachchillage, et al.). This patient has a clinical scenario consistent with recurrent venous thrombotic event. The records suggest that the second episode was an unprovoked event, which raises the likelihood for an underlying thrombophilia. Given the history of intracranial hemorrhagic events in the past, knowing his underlying hypercoagulable status would aid in making the decision in duration of anticoagulation. Overall, this patient would likely benefit from Factor V Leiden mutation testing. Therefore, the requested Factor V Leiden genetic testing is 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 requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in medical oncology with subspecialty certifications in hematology and internal medicine and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in hematology and oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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

A 26-year-old male enrollee has requested authorization and coverage for the NESS L300 Foot Drop System and NESS H200 Wireless Hand Rehabilitation System for treatment post stroke. Findings:  Three physician reviewers found that the patient has a medical history of a left hemispheric intracranial hemorrhagic stroke, due to an arteriovenous malformation (AVM). The patient has right hemiplegia and foot drop. The patient has participated in physical therapy and wears an ankle-foot orthosis (AFO). He has been prescribed the NESS L300 Foot Drop System for his foot drop and the NESS H200 Wireless Hand Rehabilitation System to improve his hand function. The Health Plan has denied coverage for these devices on the basis that they are considered investigational.In this situation, the prescribed functional electrical stimulation devices remain of unproven efficacy (Weber, et al.; and Stein, et al. 2006). The studies to date are small case reports within stroke, multiple sclerosis, and spinal cord injury patients (Stein, et al. 2010). The available literature does not present evidence of long-term functional change beyond what would be expected with standard care for the lower or upper extremity (Stein, et al. 2006 and Everaert, et al.). All told, the NESS L300 and the NESS H200 devices have not been shown to be advantageous over standard care for foot drop secondary to stroke. In the absence of adequate scientific evidence that the requested NESS L300 and NESS H200 devices are likely to be more efficacious than standard modalities in this setting, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee has requested reimbursement for occipital nerve injections that were provided. Two out of three physician reviewers found that medical literature supports that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Researchers performed a meta-analysis in 2017 and found that when compared to control intervention, greater occipital nerve (GON) block intervention can significantly alleviate pain, reduce the number of headache days and medication consumption, but have no significant influence on the duration of headache per four weeks for migraine patients. In this case, the patients pain complaints are corroborated by medical history and physical examination. In particular, the patient has well-documented occipital neuralgia. In addition, the records indicate that the patients pain has been non-responsive to multiple rounds of conservative measures including non-steroidal anti-inflammatory drugs (NSAIDs), neuropathic agents and activity modification. The use of occipital nerve blocks is well supported by medical literature, and the patient experienced documented efficacy and improved function from the first occipital nerve block to substantiate repeat injections. Thus, the occipital nerve injections that were likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Final Result: The reviewers determined that the services at issue were 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:  Physician reviewers 1, 2 and 3 are board certified in anesthesiology with subspecialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis who presented for a breast examination. Findings:  The physician reviewers found that  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, she presented with a palpable mass.  Tomosynthesis, especially in patients with dense breast tissue, has been shown to be better able to delineate and characterize masses. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition to the need to evaluate the palpable mass, in patients with heterogeneously dense breast tissue, tomosynthesis offers the advantage of possibly demonstrating additional areas of concern. In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two of three reviewers determined that 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:  Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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:  The enrollee is requesting authorization and coverage for breast reduction surgery. The enrollee had breast augmentation and is now experiencing back pain, requiring a back brace. She also complains of burning and pain to her chest.  A physical therapy letter indicates the size and heaviness of the enrollees breasts are affecting her entire body.Findings:  Notes by her physician describe the size of the current implants. There are no records of the previous surgery, and there is no indication as to what size implant would be desired. There are multiple records from pain management. It is not clear from review of the records if weight of the current implants is the total for both sides or for each, but even if half per side, they could cause discomfort for this enrollees body frame size. However, they would not be attributed as the causative agent for bulging and extruding discs in the cervical spine and lumbar spine, as well, from her neck to lower back. Notes indicate the enrollee also has a history of a fall and shoulder dislocation. A mastopexy/lift reconstruction procedure is not medically indicated in this case, as the enrollee does not have breast hypertrophy, she has large implants. Removing the implants, which are currently intact, and replacing them with other ones is not medically consistent treatment, since the implants are the source of pain. Even if smaller in size, they are still significant in weight. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified in plastic and reconstructive 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old male enrollee has requested continued acute inpatient rehabilitation services for the treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that while this patient made very minimal progress initially, his alertness and participation has improved considerably. It is noted that although he required cues before, this patient is now responding spontaneously and tracking conversations. He is now able to participate in hand over hand grooming and has been able to transfer side to side.  This patient was previously dependent. He has recently been able to take small bites of food and has answered appropriately to yes and no questions. Therefore, I believe it is medically necessary that this patient remain in inpatient acute rehabilitation for continued progress.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SmartPill wireless motility capsule. Findings:  Two of the three physician reviewers found this patient has considerable underlying disease which is likely affecting him. However, the information provided by the SmartPill study is likely to provide little benefit in the care of the patient. The patient is already on a modified diet for the management of gastroesophageal reflux disease. This diet overlaps the recommendations for gastroparesis, including the intake of low-fat, small frequent meals. Additionally, treatment of constipation, whether due to slow transit or another etiology, includes the use of laxatives and maintenance of hydration. In summary, the management of this patient is not likely to change based on the results of the SmartPill. In sum, SmartPill wireless motility capsule is not likely to be superior over other available methods of evaluating 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee requested authorization and coverage of Synvisc injections for the treatment of moderate to severe osteoarthritis of the left knee. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested injections are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for biofeedback peri/uro/rectal (units: six). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients medical condition. The submitted documentation supports the medical necessity of the requested services. Medical research by Alame (cited above) and Thapar (also cited above) has showed that there are a number of causes for constipation related to obstructed defecation syndrome, (per the symptoms in this case), and pelvic floor dysfunction, (per the testing in this case), such as rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidoceles, or enteroceles. Some of these potential causes are structural anatomical issues. However, others potential causes are functional issues with normal anatomy. If functional abnormalities are present, lifestyle modification and biofeedback therapy can be effective. The American College of Gastroenterology (ACG) guidelines for the management of benign anorectal disorders recommend anorectal manometry to determine whether a functional disorder is present, and a physical functional performance test, such as a balloon expulsion test, is also warranted when evacuation or outlet disorder is suspected. In this case, this testing has  been performed and it showed dysfunction. Additionally, the patient has intermittent incontinence. The American Society of Colon and Rectal Surgeons clinical practice guideline for the treatment of fecal incontinence states that biofeedback should be considered as an initial treatment for patients with incontinence and some preserved voluntary sphincter contraction. The American College of Gastroenterology guideline for the management of benign anorectal disorders states that pelvic floor rehabilitative techniques, such as biofeedback are effective and superior to pelvic floor exercises alone in patients with fecal incontinence who do not respond to conservative measures. Medical literature supports the use of biofeedback as an effective therapy for fecal incontinence. For these reasons, biofeedback peri/uro/rectal (units: six) is 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Mekinist/trametinib. Findings:  The physician reviewer found that the physician reviewers found there is sufficient support for the requested medication in this clinical setting. Mekinist has been shown in multiple studies to have clinical response, specifically in patients with plexiform neuroma and also in low grade gliomas in patients with neurofibromatosis, type 1. Furthermore, research shows excellent two-year progression-free survival.  Because neurofibromatosis, type 1 is a cancer predisposition syndrome, treatment with radiation should be withheld unless there are no other options. Otherwise, the risk of secondary malignancies is greater.  In addition, chemotherapy versus targeted therapy has a higher side effect profile. In sum, Mekinist/trametinib is likely to be more efficacious than other treatment options. Final Result: Two of the three reviewers determined that the requested medication 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: Physician reviewers 1,2 & 3 are board certified in pediatrics with sub-specialty certification in pediatric hematology-oncology and are 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

The parent of a 5-year-old male enrollee has requested coverage for continuation of applied behavioral analysis therapy with an additional administer/coordinate therapies for treatment of the enrollees autism spectrum disorder. Findings:  Three physician reviewers found that this case concerns a 5-year-old male with a diagnosis of pervasive developmental disorder (PDD). He was the product of a premature fraternal twin pregnancy and was delivered by Cesarean-section weighing 5 pounds 1 ounce, without neonatal difficulties. His early development was normal with walking at 1 year, first words at 1 12 years, and phrases by 3 years. Despite this, his expressive speech developed poorly and the patient had nearly continuous tantrums and was readily frustrated. At the age of 3, he was placed in a school early intervention program. His family history revealed that a paternal brother has possible Aspergers syndrome and his twin sister has a PDD and epilepsy. The patients provider recommended applied behavioral analysis (ABA) therapy. The patient began receiving ABA therapy with reported benefit. A request has been made for continuation of ABA services at a frequency of 12 hours per week with an additional 2 hours per week for administration/coordination of therapies. The Health Plan has denied the request for coverage on the basis that it is considered investigational.  This young patient has a diagnosis of PDD, which is a subgroup found within the autism spectrum of disorders (ASD). He has severe communication dysfunction as well as an inability to develop social relationships. One provider reported significant improvement in the patients problems since the introduction of ABA therapy.  Beginning in the 1960s, Dr. Lovaas pioneered an intensive one-on-one behavioral program for autistic children. When compared to conventional school programs, these programs showed promise. Decades later, Eikeseth and colleagues reported on a controlled study comparing young patients who received ABA therapy versus those who did not receive ABA therapy. The authors concluded the patients treated with ABA demonstrated significant gains in speech, communication, and behavior. Myers and colleagues stated that, Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In terms of long-term outcome, Sallows and Graupner reported results at 4-year follow-up that showed substantial improvement in patients who received ABA therapy.  For these reasons, I have determined the requested therapy is likely to offer the patient greater benefit than any treatment alternative. He should receive the requested 12 hours of ABA therapy per week, and 2 hours of coordination and planning.