Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) of the heart without dye with quantitative evaluation of coronary calcium for evaluation of her medical condition.  Findings: Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. There has been growing evidence on the use of coronary artery calcium (CAC) screening in better-studied cohorts of patients and asymptomatic individuals. CAC scoring has an increasingly high level of quality evidence on its role in risk stratification of asymptomatic patients. The accumulating evidence suggests that asymptomatic individuals with an intermediate Framingham risk score (FRS) may be reasonable candidates for coronary heart disease testing using CAC as a potential means of modifying risk prediction and altering therapy. The American College of Cardiology Foundation judged that it may be reasonable to consider use of CAC measurement in intermediate risk patients based on available evidence that demonstrates incremental risk prediction information in this selected patient group. This conclusion was based on the possibility that such patients might be reclassified to a higher risk status based on high CAC score, and subsequent patient management may be modified. Testing using CAC would reclassify many to a higher or lower risk category and improve health outcomes by treating those with asymptomatic coronary atherosclerosis to evidence based medical therapy and those with low risk to careful follow-up. All told, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department and was diagnosed with a potentially malignant, life threatening large abdominal tumor. Due to his emergent presentation, he underwent partial bowel resection. Based on the clinical documentation submitted for review, the patient received emergency medical services for an emergency medical condition on the date of service in dispute. Final Result: The reviewer determined that the patient receives emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees Angelman syndrome. Findings:  The physician reviewer found that Angelman syndrome is a genetic disorder characterized by deletion of the maternal chromosome 15q11-q13 and paternal uniparental disomy. Features include severe developmental delay and/or cognitive delay, severe speech impairment and gait ataxia. Microcephaly and seizures are also common. The literature supports speech therapy and occupational therapy for patients with this syndrome.  The medical literature notes that management should include physical therapy, occupational therapy, and speech therapy with an emphasis on nonverbal methods of communication, including augmentative communication aids and signing. As noted by Guerrini and colleagues, cognitive, language, and orthopedic problems must be addressed with vigorous rehabilitation programs, including early physical therapy, which may help to develop communicative skills and prevent severe scoliosis and subsequent immobility. This patient has documented deficits in speech and language skills, as well as deficits in fine and gross motor skills. Standard of care includes speech therapy and occupational therapy intervention for children with Angelman syndrome to address these deficits. In this patients case, speech therapy and occupational therapy are medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested vaginal hysterectomy for treatment of the enrollees pelvic pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This is a patient with non-cyclic pelvic/abdominal pain that reportedly is brought on with a full bladder or rectum.  She is possibly menopausal, although there is no documentation of laboratory tests to assess her status.  The appeal documentation states that she has had ultrasounds that showed a fibroid and later adenomyosis, but the ultrasound report from the recent study showed neither.  If she actually has adenomyosis or endometriosis as a cause of her pain, this is likely to resolve after menopause.  There is no indication that alternate therapies have been tried and failed.  Her pain may in fact be bowel or bladder related, and no other evaluation has been done.  It is not clear that her symptoms are related to her uterus, which is normal on ultrasound.  It is likely that her pain may persist even after hysterectomy.  In this case, non-gynecologic causes of pain do not seem to have been ruled out, her ultrasound shows a normal uterus, and other therapies for pelvic pain have not been tried.  All told, the requested vaginal hysterectomy is not medically indicated for the treatment of this patient.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 obstetrics and gynecology 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 Benicar for treatment of her medical condition.  Findings:  The physician reviewer found that based on the records provided, the patient has essential hypertension that is being managed with an angiotensin receptor blocker medication, Benicar. There is no documented trial of other antihypertensive medications in the same class and no documented intolerance to other antihypertensive medications in the same class.  There are several other angiotensin receptor blocker medications in the same medication class that would be considered reasonable and appropriate to manage the patient's hypertension. Since efficacy and side effect profiles of antihypertensive medications are usually similar in medications of the same class, the Health Plans alternative should be effective and tolerated by the patient. As such, the medical necessity of Benicar has not been established in this case.   Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A male enrollee requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Three physician reviewers found that 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The requested Harvoni is medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 34-year-old male enrollee has requested emergency services for the treatment of his back pain. Findings:  The physician reviewer found that there is no documentation to support a neurologic emergency. The record does not reflect any loss of bowel or bladder function, any focal limb weakness or any radicular pain. The patient appeared to be neurologically intact. His imaging studies were read as negative and he was discharged in stable condition. There is insufficient documentation in the medical record to support a finding of the prudent layperson definition of an emergency condition.   In this case, a prudent layperson would not have sought immediate medical attention for his complaint of back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 17-year-old female enrollee has requested  Remicade injections for treatment of the enrollees chronic non-infectious osteomyelitis. Findings:  Three physician reviewers found that the office note included in the records describes a patient who seems to be doing quite well with methotrexate as primary therapy, although her elevated sedimentation rate and mild anemia with increased white count suggest there may still be some degree of underlying inflammation. The available literature concerning chronic recurrent multifocal osteomyelitis is rather limited. The exact nature of this condition remains uncertain, but it is thought by many experts to be an auto-inflammatory disorder with no defined best treatment. Many patients respond significantly to naproxen or prednisone, and some patients respond well to azathioprine or methotrexate. The most impressive anecdotal information relates to pamidronate given intravenously at intervals of one to three months. The available literature concerning anti-TNF or anti-IL-1 therapy for chronic recurrent multifocal osteomyelitis consists of small uncontrolled groups of patients, with mixed results and partial benefits.The submitted documentation does not include historical information regarding the patient's treatment history, and her pediatric rheumatologist describes her most recent evaluation in rather positive terms, noting that the patient is nearly asymptomatic, and remains fully active without limitation.  Thus, Remicade is not indicated based upon the submitted documentation and is not likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested speech therapy, one hour per week, for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that speech therapy is effective for expressive and receptive language delays. In this case, the patient does not have expressive or receptive language delays. A recent speech evaluation revealed a total language score of 104. As such, the patient does not meet clinical indications for individual speech therapy. For the reasons stated, speech therapy, one hour per week is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 54-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the wrist. Lynch syndrome is a well-recognized inherited disorder which predisposes the patient to cancer in multiple organs including colon, uterus, stomach, small bowel, pancreas and the urinary tract. A variant known as Muir-Torre syndrome is associated with cutaneous lesions including cancer of superficial soft tissues but not bone. This patient has a palpable cystic lesion along the radial aspect of the left wrist, which is a common location for ganglion cyst. This patients records do not include findings of a solid mass on ultrasound. For these reasons, MRI of the wrist is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation 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: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee who has requested authorization and coverage for a standing referral to an otolaryngologist.  The health plan has denied this request indicating that a standing referral is not medically necessary for treatment of the enrollees ear infections.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested standing referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery for treatment of the enrollees morbid obesity. Findings: The physician reviewer found that although this patient is morbidly obese and may benefit from bariatric surgery with a BMI of 59 kg/m2, the medical necessity of bariatric surgery has not been met. Specifically, there is no documentation of completion of a multidisciplinary evaluation documenting that this patient has completed dietary and behavioral education and evaluation demonstrating that the patient is an appropriate candidate for bariatric surgery. In addition, dietary and psychological evaluations were not available for review. The patient has reportedly failed dietary efforts in the past. However, without a multidisciplinary evaluation, the medical necessity of the requested bariatric surgery has not been established for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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

A 40-year-old female enrollee has requested for a myelography, physician visit, and lumbar discography for evaluation of her Behcet syndrome for placement of an intrathecal catheter.  Findings:  The physician reviewer found that Behcets disease is essentially a chronic disturbance in the bodys immune system. In severe cases, the nervous system can be involved, (i.e. Neuro-Behcets) and occasionally patients with severe Behcets require large doses of pain medicine, usually given intravenously or through an intrathecal catheter. This patient had a permanent intrathecal catheter and pain pump inserted, which was noted to be reasonably effective. The anesthesiologist who performed the procedure also performed a lumbar discography and myelography as well. Considering the fact that misplacement of an intrathecal catheter is an undesirable result, it was reasonable for the provider to perform the imaging for achieve a functional outcome.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for nitazoxanide twice daily for a therapy duration of 14 days. The documentation and current medical literature support the requested 14-day course. The risk of damaging a transplant with inadequate treatment supports the medical necessity of the prolonged course of therapy. Researchers found that a delay in treatment in a solid organ transplant patient may result in serious complications including acute renal failure. The authors concluded that, therapy with nitazoxanide (at least 14 days) may facilitate recovery. For these reasons, nitazoxanide twice daily for a therapy duration of 14 days is medically necessary for treatment of this patient. 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 subspecialty certification in nephrology 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 seven-year-old female enrollee has requested sensory integration therapy for the treatment of the enrollees cerebral palsy and cortical visual and developmental speech delay. Findings:  Two physician reviewers found that the patient's physician ordered one month of sensory integration therapy. The childs parent is seeking reimbursement for these services. Sensory integration therapy is not a proven intervention for patients with cerebral palsy. There is no evidence base for this intervention for this diagnosis. Additionally, it is unclear why one month of therapy was ordered.
Appeal type: Experimental/Investigational
Decision: Upheld

A 70-year-old male enrollee has requested vertical axial decompression for the treatment of his neck pain. Findings:  Three physician reviewers found that there is a lack of scientific literature supporting the use of decompression treatment, and there are no large controlled studies validating the efficacy of decompression treatment. There are a number of appliances on the market offering spinal decompression. There is no supportive large scale scientific data showing the efficacy of these devices. There is also no data to suggest that vertebral axial decompression is more beneficial than alternative treatments such as NSAIDs, muscle relaxants and pain medications.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Emgality 120 mg/mL syringe. In this case, the patient has a history of chronic migraines. The patients provider has recommended continued treatment with Emgality given the improvement in the frequency of the patients migraines. Per the American Headache Society (AHS), a patients records should document failure of oral preventative medications to support an indication for a calcitonin gene-related peptide (CGRP) monoclonal antibody agent such as Emgality. Every chronic migraine treatment plan should include both prophylactic treatment of reduction of headache days and severity and as-needed treatment of exacerbations. Current evidence-based prophylactic medications for episodic migraine include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate. CGRP monoclonal antibodies are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. Emgality is an injectable preventive therapy approved for episodic and chronic migraine. Per the U.S. Food and Drug Administration (FDA), Emgality is a monoclonal antibody targeting CGRP. Overall, this patients records do not adequately document trials of oral preventative medications to meet the AHS criteria for treatment with Emgality. Therefore, the requested Emgality 120 mg/mL syringe is not medically necessary for 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 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: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested bariatric surgery for treatment of his morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria set forth by the National Institutes of Health for weight loss surgery.  His BMI is over 40, and prior attempts at weight loss have failed, including a prior supervised, weight loss program. The Health Plan has denied coverage for bariatric surgery because the medical records fail to demonstrate that a glandular disorder has been ruled out, or that heart and lung disease screening tests were performed to medically clear the patient for surgery. In this patients case, an evaluation by a cardiologist is medically appropriate prior to proceeding with bariatric surgery. Additionally, ruling out a glandular disorder, such as a thyroid disorder, is medically appropriate in this patients case.  A complete workup prior to bariatric surgery is required. All told, the requested bariatric surgery is not medically indicated for the treatment of this patient at this time.