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

A 60-year-old female enrollee has requested a referral for consultation with an allergist/immunologist for the treatment of her rhinitis. Findings:  The physician reviewer found that patients with persistent symptoms despite standard medical management and environmental avoidance should be referred to allergy specialists for further identification of responsible allergies. The UptoDate guidelines referenced by the Health Plan state, Primary care physicians treat the majority of patients with allergic rhinitis, and often initiate therapy empirically, identifying triggers only through the clinical history. This approach may be adequate for many patients, although those whose symptoms are severe or refractory to therapy should be referred to an allergy specialist for a more definitive evaluation. Based on the submitted evidence, it appears this patients symptoms have been refractory to trials of several medications. Furthermore, although the results of the patients RAST testing were negative, Williams suggests in his publication that RAST results have been demonstrated to be less sensitive than those of percutaneous skin tests. Generally, skin testing is considered the optimal way of determining allergic sensitivity and is endorsed widely throughout the medical community. Consistent with Wallace and colleagues practice parameters, the clinical records presented for review, and the relevant scientific evidence, this patient should be referred to an allergy specialist for additional evaluation of her symptoms and further testing.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female with varices that she treats with compression stockings. The patient reports that a pair of compression stockings only lasts for three months. She has requested authorization for four pairs of compression stockings per year. The Health Plan indicates more than two pairs of compression stockings per year are not medically necessary for treatment of the patients medical condition.The standard recommendation for compression stocking use is to replace the stockings every three to six months, depending on wear and tear. The stockings are used to apply gradual pressure. Once the stockings lose their compressive properties they are no longer effective. Therefore, it is medically necessary to replace the stockings when they become loose. The use of up to four pairs of compression stockings per year is within the manufacturers recommendations. Since the patient reports less compression after three months of constant use, four pairs of stockings per year are medically reasonable and should be authorized. Therefore, I have determined that the requested supplies are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old man with a T1c adenocarcinoma of the prostate, Gleason 4+5=9 and a PSA of 8.7. Seven of the 10 biopsies contained tumor, which indicates a relatively large percentage of the volume of the prostate is involved. Based upon Partins Tables the probability that the patients tumor is confined to the prostate only is 37% with 13% chance of involvement of the seminal vesicle, 48% chance of involvement of the capsule and 3% chance of involvement of the lymph nodes. The patient has received three months of hormonal therapy. A request has been made for brachytherapy. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary.Brachytherapy is a very effective therapy for a smaller volume of prostate cancer. Proton beam therapy is a better option for patients such as this patient because it can provide a higher dose uniformly to the prostate, the capsule, and the seminal vesicles. Proton beam therapy in combination with external proton radiation to the pelvis will offer the patient a better outcome since it will encompass more of his disease than brachytherapy. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed.Findings: The physician reviewer found that the patient who was asymptomatic with respect to her breasts.  However, the patient has a remote history of breast cancer.  On the date of dispute, the patient underwent a routine screening and surveillance mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. 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.  Surgical clips were identified. Her breasts were described as primarily fatty withscattered fibroglandular elements.  The patient has requested reimbursement for the breast tomosynthesis portion of the examination but the Health Plan has denied reimbursement.  Per the Health Plan, digital breast tomosynthesis performed on the dated of dispute was investigational for the evaluation of 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, on the basis of breast density, one could not justify the superior effectiveness of tomosynthesis. But in terms of surveillance in patients who have had breast cancer, studies have demonstrated that when digital breast tomosynthesis was applied in a study, screening sensitivity had improved. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. Moreover, a study allowed avoidance of unnecessary biopsy. Therefore, digital breast tomosynthesis performed on the date of dispute 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: Physician reviewers 1,2 & 3 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 reimbursement for Endometrin inserts. The Health Plan has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees high-risk pregnancy. The submitted documentation does not support the medical necessity of the medication at issue. In this enrollees case, the provider has recommended the use of vaginal progesterone suppositories to help prevent preterm labor. This recommendation occurred when a growth scan of the fetus at 33 weeks two days noted a shortened cervical length of 1.4 cm. The enrollees cervix had previously been measured in mid-trimester during a routine fetal anatomy scan. The cervix was found to be normal in length of greater than 3 cm. After the shortened cervix was noted, the enrollee underwent a preterm labor evaluation and started on vaginal progesterone. Vaginal progesterone has been found to be helpful to prevent preterm labor in select sub groups of enrollees. The American College of Obstetricians and Gynecologists (ACOG) recommends the use of vaginal progesterone as an option to reduce risk of preterm labor include the following criteria; asymptomatic women; singleton gestation, no prior preterm birth; and an incidentally identified short cervical length that is less than 20 mm before 24 weeks. Although vaginal progesterone has been found to be helpful in prolonging gestation in asymptomatic enrollees who happen to have a shortened cervix, this enrollee differs from the ACOG criterion in that the length of the cervix was normal in the mid-trimester and only after the mid-trimester did the cervical length change. In addition, the end-point in several major studies was 33-33.6 weeks, and this enrollee was 33 weeks two days. Since this enrollee was 33 weeks two days and had a normal cervix in the second trimester, the enrollee falls outside of the criteria created by these studies. Therefore, Endometrin inserts were not medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the medication at issue was not medically necessary for treatment of the enrollees 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

A 60-year-old male enrollee has requested authorization and coverage for a repeat course of Synvisc injections for treatment of the enrollees right knee patellofemoral arthrosis.  Findings:  The physician reviewer found that hyaluronic acid (Synvisc) is a high viscosity mucopolysaccharide found in umbilical cord, vitreous body and synovial fluid. The available peer-reviewed medical literature has yielded conflicting conclusions regarding the efficacy of Synvisc in the treatment of knee pain. A powerful placebo effect has been documented with use of saline as compared to hyaluronan, with no statistically significant difference in the two study cohorts (Jorgenson, et al.). While the complication rate from repeated injection is statistically low, there is some increased risk as series are repeated over time. These risks include a sensitization of the patient to the byproducts present in the extract. The fact that this patient has not had an allergic reaction to date does not mean that he is not vulnerable to future allergic reactions through a process of sensitization by reason of repeated dosages. There is also the possibility of introducing bacteria from the skin with an intraarticular injection. In summary, considering the weak clinical evidence for efficacy of hyaluronan over saline and considering the possibility of sensitization through repeated dosages, the request for a repeat series of Synvisc injections is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested partial hospitalization for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the services at issue. Continuing partial hospitalization treatment stay requires the patient to show emergence of new problems that cause significant distress relative to the maintenance of sobriety, compromise with respect to being able to maintain sobriety, and in the face of discharge planning significant decompensation. In this case, the patient does not meet these criteria. Despite some minor problems with impulse control he participated well in the program, was making gains, and was ready to step down to a lower level of care. The patient did demonstrate a relapse which resulted in readmission on the date indicated. However, there was no indication that the patient required partial hospitalization services during the dates of service at issue. He continued to have support from his family, he had no significant medical comorbidity, he was not resistive to treatment, and was participating in the program. The patient did not require withdrawal based services and did not show a coexisting psychiatric condition which required more intensive services. For the reasons provided, partial hospitalization level of care was not indicated. All told, the partial hospitalization treatment provided the time frame indicated was not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a lumbar traction device for treatment of his medical condition. Findings:  Three physician reviewers found that there is insufficient high-quality data from peer-reviewed published studies to conclude that the mechanical lumbar traction is clinically effective in the management of chronic mechanical low back pain. Overall, the literature does not support the requested device in this clinical setting.  In sum, the requested device is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy such as exercise and topical thermal modalities. Final Result: Three reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in physical medicine and rehabilitation and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Stelara for treatment of her Crohns disease.  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Despite the success of anti-tumor necrosis factor therapy in Crohns disease, there remains a need for biologic therapy that targets other immune pathways of disease.  Stelara is a fully human monoclonal immunoglobulin antibody which has been studied in two phase 2 randomized, double-blind, placebo-controlled trials in Crohns disease.  Per the literature, patients with an initial response to Stelara had significantly increased rates of response and remission with Stelara as maintenance therapy.  There is a lack of treatment options in this clinical setting, and the patient has responded to Stelara.  All told, Stelara is likely to be more efficacious than other treatment options.  Final Result:  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. The Health Plans denial should be overturned.   Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee requested authorization and coverage of a nasal endoscopy from an out-of-network provider for treatment of decreased sense of smell and taste.  The health plan denied the enrollees request indicating that it is not medically necessary for the enrollee to obtain services from the out-of-network provider.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for DaT SPECT scan of the brain. The Health Plan has denied this request indicating that the requested services are investigational for evaluation of the enrollee who presented with parkinsonian features.Findings The medical evidence indicates that Parkinsons disease is the second most common neurodegenerative disease.  Its diagnosis is determined by clinical means, which can lead to error. There are studies that have indicated that patients with presumed Parkinsons disease did not have Parkinsons. Several Parkinsons like diseases including multiple system atrophy, progressive supranuclear palsy, corticobasilar degeneration, and essential tremor can have Parkinsonian features and make them difficult to distinguish. Dopamine transporter scan (DaT) uses SPECT imaging to determine presence, location, and amount of dopamine transporters in dopaminergic cells. It is effective in distinguishing those individuals with parkinsonian syndromes from those with Parkinsons diseases, which can improve and change management of a patient. Accordingly, the requested DaT SPECT scan of the brain is likely to be more beneficial for the evaluation of this patients medical condition than any available standard therapy.Final Result: All three reviewers determined 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 reviewers are board certified in neurology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 26 hours per week of direct applied behavioral analysis (ABA) therapy, 18 hours per month of supervision and four hours per month of parent training for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that colleagues indicate that a minimum of two years of intensive ABA therapy is necessary for sustained behavioral and intellectual improvement in an autistic child. In addition, colleagues emphasize early intervention and a minimum of 20 hours of ABA therapy is the most successful program for behavioral improvement in an autistic child. In this case, the patient did not receive early ABA therapy before the age three. Thus, it is medically necessary for this patient to receive ABA therapy. Based on the clinical documentation records submitted for review, ABA therapy at the frequency of 20 hours per week of direct therapy, eight hours per month of supervision and four hours per month of parent training are medically necessary for treatment of the patients autism. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty 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: Medical Necessity
Decision: Upheld

A 63-year-old female has requested epoetin alfa injections (1000 units) for treatment of her end stage kidney disease.   Findings:  The physician reviewer found that in this case, the patient had hemoglobin greater than 11 when the case was reviewed, at which time epoetin alfa injections were denied. The patients more recent labs still show hemoglobin at 10.5. The National Kidney Foundation is a founding sponsor of the Kidney Disease Improving Global Outcomes (KDIGO) group which has generated recommendations. Although the guidelines recognize that some patients with hemoglobin greater than 10 may benefit from epoetin alfa, there is no indication in this patients records of a clinical indication to start epoetin alfa injections. The provider has requested the lowest possible epoetin alfa dose at 1000u. However, it is not medically necessary for this patient to be started on epoetin alfa at this time. If this patients hemoglobin drops below 10g/dl, epoetin alfa use should be approved if the patients iron stores are adequate.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old female enrollee requested growth hormone medication Genotropin for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this patient has extreme short stature likely due to GH deficiency. Her height is more than three standard deviations below normal for age and gender, and she has a normal height-to-weight ratio. She is not likely to catch up to a normal height and is already showing signs of central puberty, indicating a limited time window to intervene to improve her height until epiphyseal fusion. Although her growth factors were normal, her peak GH response on two standard provocative tests was less than 10 ng/mL, and laboratory tests have ruled out other causes of short stature. Thus, this patient meets the generally accepted criteria for GH deficiency. For these reasons, GH therapy with Genotropin is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested a pain management specialist for treatment of her right shoulder impingement syndrome. Findings:  The physician reviewer found that the American Academy of Orthopedic Surgeons (AAOS) recommends initial management of shoulder impingement syndrome with ice packs, rest, avoidance of overhead activities, NSAIDs, stretching exercises, steroid injections, as well as supervised physical therapy. Only some of these treatments have been utilized by this patient. This patient has a history of persistent shoulder pain and a radiograph that may suggest a spur versus a loose intra-articular body. A referral to a pain management specialist for this patient is not medically necessary at this time due to the absence of a clear orthopedic diagnosis and the lack of evidence demonstrating the patient has completed an adequate course of conservative therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested left knee osteochondral allograft for the treatment of her knee pain. Findings:  Two physician reviewers found that it is unclear from the record what conservative measures were rendered after the arthroscopic procedure. There is no documentation of formal physical therapy or the patients response to physical therapy. There is no indication that a cortisone injection was administered either diagnostically or as a potentially therapeutic modality. There is no apparent consideration of visco supplementation for early degenerative joint disease with well maintained joint spaces. The records do indicate the patient has lesions in the trochlear and the patellofemoral articulation as well as the medial femoral condyle but there is no documentation that the lesions were sized.