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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of her cardiovascular risk. Findings:  Three physician reviewers found that in this circumstance guidelines for the management of cardiac risk have been established and these guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), apolipoprotein B, sub-classifications of LDL, high density lipoprotein (HDL) subclasses, lipoprotein (A), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the testing at issue was 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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 41-year-old female enrollee requested authorization and coverage for continued Botox injections.  The health plan has denied this request indicating that Botox injections are considered investigational for treatment of the enrollees migraine headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Linzess and (2) surgery to treat irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that The U.S. Food and Drug Administration (FDA) approves the use of Linzess for the treatment of irritable bowel syndrome with constipation, and chronic idiopathic constipation. The American Gastroenterological Association guidelines for the treatment of constipation recommend the use of osmotic and stimulant laxatives prior to advanced agents such as Linzess, stating, A newer agent should be considered when symptoms do not respond to laxatives. In this case, the records noted that the patient reported diarrhea. As Linzess would make diarrheal symptoms worse, it is not medically indicated. Regarding the treatment of GERD, Moore and colleagues note that first line treatments for GERD involve mainly lifestyle and non-surgical therapies. In this case, the documentation does not reflect that the patient has tried and failed medical therapy or has complications due to GERD. The documents do not show a preoperative workup and an endoscopy has not established a diagnosis of GERD. Surgical intervention is also not recommended for the treatment of IBS. Given current medical literature, the requested medication and service are not medically indicated in this clinical setting. Therefore, (1) Linzess and (2) surgery to treat IBS and GERD are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication and service are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Overturned

This patient is a 43-year-old female with chronic active hepatitis C, genotype 1a who was treated with PEG Intron and ribavirin in 2004, and relapsed after the completion of therapy. She has no history of suicide or depression. The patients last liver panel revealed normal bilirubin, AST, ALT, total protein, albumin, total bilirubin, PT and INR. The HCV-PCR in December 2005 was 21,099,000 Iu/ml. Her liver ultrasound revealed mild hepatic steatosis without focal lesions.  When last evaluated by her hepatologist, the patient was doing well and showed no signs or symptoms of decompensated liver disease. She had no symptoms of mental confusion or forgetfulness. The patient has requested authorization for retreatment with Infergen and ribavirin therapy.  The Health Plan denied her request based upon a determination that the therapy is not medically necessary.Therapeutic options for hepatitis C treatment failures include retreatment with pegylated interferon, Infergen plus ribavirin, maintenance interferon therapy, and watch and wait for the development of new agents.  Infergen induction therapy together with subsequent ribavirin combination therapy showed promising results in two clinical trials conducted by Kaiser et. al. Two more recent trials have corroborated the Kaiser findings and there is significant interest in the use of Infergen for the treatment of nonresponders and relapsers.  Currently there is a large multicenter trial underway, and if response rates are confirmed we will be in a far better position to treat these patients. Although the proposed therapy is not yet FDA approved, it is being used extensively by hepatologists nationally and internationally to treat relapsers and nonresponders to previous combination therapy. The patient responded to 48 weeks of combination therapy with pegylated interferon and ribavirin in 2004, and later relapsed. She is genotype 1a and has a high viral load.  Based upon the studies citied above, the patient is an appropriate candidate for Infergen and ribavirin combination therapy.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

An 80-year-old female enrollee has requested the medication Malarone for the treatment of her malarial prophylaxis. Findings:  The physician reviewer found that the patients dermatologists recommendation not to take doxycycline due to the patients skin conditions was medically appropriate. The remaining choices available to the patient were Lariam and Malarone. Malarone would be the preferred agent for this patient because of the dizziness that Lariam can cause as indicated in the medications warning brochure. In addition, it is noted that dizziness may persist after taking the medication. Thus, the use of Lariam was not optimal given the patients medical history of blackouts and dizziness. All told, Malarone was the most appropriate antimalarial drug for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Kalydeco 150 mg tablets every 12 hours for one year. Current medical literature indicates that although this patients mutation is not a gate mutation defect, there is evidence that this particular mutation has the capacity to be stimulated by potentiators, such as ivacaftor (Kalydeco). Recent data shows that the W1282X mutation can be coaxed to have high ion channel activity by some medical therapies, such as Kalydeco, that were designed for other mutations (Mutyam, et al.; Xue, et al.). This patient presents with clinically worsening disease despite treatment with antibiotics, manual and pharmacological airway clearance treatments, and nutritional supplementation. This patients weight loss, severely deteriorated lung function, and high insulin demands may benefit from use of Kalydeco (Mutyam, et al.). The patient has post-tussive vomiting, which is consistent with severe reactive airway disease that will contribute to poor nutrition and further weight loss if left untreated. All told, the requested Kalydeco 150 mg tablets every 12 hours for one year 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 pulmonary disease with subspecialty certification in critical care medicine 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 20-year-old male enrollee has requested substance abuse residential rehabilitation treatment for treatment of his substance abuse.  Findings:  The physician reviewer found that based on the available medical records, this patient presented with a history of substance abuse but there was no psychiatric admission, evaluation, nursing notes, or any other physicians documentation provided for review. Further, the patients substance abuse history does not support admission to residential treatment. The patient does not have any reported prior treatment at the partial hospitalization program, or outpatient level of care for substance abuse. He had no comorbid psychiatric or medical conditions that would require treatment in a 24-hour setting. In addition, he did not meet the American Society of Addiction Medicine (ASAM) criteria for residential level of care. He could have been treated on an outpatient basis with community based sober support systems such as a 12-step program. All told, the substance abuse residential rehabilitation treatment provided from the time period specified was not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been superior over other modalities.  There have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography.  As noted by Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Rafferty and colleagues noted that the addition of breast tomosynthesis to digital mammography increased diagnostic accuracy.  In this case, a mass was noted on routine mammography.  Breast tomosynthesis provided even better delineation and revealed that the nodule was one-half the size that was expected.  All told, digital breast tomosynthesis  was likely to have been of greater benefit than other available alternatives.  Final Result: Three reviewers determined that the services at issue were 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. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left hip core decompression with concentrated bone marrow (stem cell) autograft surgery. Findings:  The physician reviewers found that there is a lack of support in the medical literature for the superior efficacy of the requested procedure in this clinical setting. In addition, platelet rich plasma and stem cell use for treatment of hip avascular necrosis (AVN) are not approved by the U.S. Food and Drug Administration. Instead, standard core decompression or hip replacement surgery have been associated with consistent superior results for patients who have undergone these standard procedures. There is a lack of high level studies in peer reviewed orthopedic literature supporting stem cell concentrated bone marrow autografting of core decompression in AVN of femoral head. As such, the requested left hip core decompression with concentrated bone marrow (stem cell) autograft surgery is not likely to be more effective than the available standard therapy such as standard core decompression or hip replacement surgery for treatment of this patient. Final Result: 2 of 3 reviewers determined that the requested procedure is 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: All three physician reviewers are board certified in orthopedic surgery 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: Overturned

The parent of a 3-year-old male enrollee has requested speech therapy 4 times per week for 30 minute sessions, and occupational therapy with sensory integration 4 times per week for 30 minute sessions for treatment of the enrollees autism.  Findings:  The physician reviewer found that these services are medically necessary based on overall evaluation of the literature, including recommendations made by Myers and colleagues. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment including speech and occupational therapies at a frequency of 3 times per week and 2 times per week, respectively, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech therapy and occupational therapy utilizing sensory integration techniques are necessary to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities. Furthermore, the proposed frequency of services is medically appropriate given the patients current functional level as documented in the records provided.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Genotropin for treatment of the enrollee, who has a reported diagnosis of pediatric growth hormone deficiency. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patients height is not more than two standard deviations below the mean for age and gender, growth velocity is normal, bone age is not delayed, and growth factors are normal. Provocative growth hormone testing has poor sensitivity and specificity for a diagnosis of growth hormone deficiency in the absence of auxological criteria consistent with the diagnosis. Thus, the fact that the patient had a suboptimal growth hormone response to testing does not indicate that he is growth hormone deficient. All told, Genotropin is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old female enrollee requested vision therapy for medical treatment of the enrollees convergence insufficiency.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. Convergence insufficiency is under the broad category of vergence dysfunction and some of the hallmark symptoms associated with this condition include blurred vision, diplopia, discomfort associated with near work, and frontal headaches. In this case, the patient seeks treatment for two of the commonly occurring symptoms, reading difficulty and frequent headaches. Evidence-based research demonstrates that vision therapy has a high success rate in the treatment and management of vergence dysfunction. Office-based vision therapy has been shown to have the greatest impact on improving the fusional ranges of patients with convergence insufficiency.  In-office therapy has also been shown to be more effective than either prescribed computerized home therapy or pencil push-ups alone (Scheiman, et al). For these reasons, vision therapy has been the method of choice for the treatment and management of convergence insufficiency and some accommodative anomalies. This patient has been noted to have difficulty with completing reading tasks in addition to her complaints of persistent headaches. As such, vision therapy is medically necessary for the treatment of the patients convergence insufficiency.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested lower back spinal fusion surgery for medical treatment of his back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, flexion extension films have not demonstrated structural instability, and there is no discussion of anticipated likely introduction of instability by a standard laminectomy, foraminotomy and discectomy.  The efficacy of instrumentation and fusion as treatment for complex regional pain syndrome remains controversial and is supported predominantly by level III and level IV case series studies.  The current medical evidence does not support the use of fusion in the management of chronic lumbosacral pain with nonspecific findings.  All told, the requested lower back spinal fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested for skilled nursing facility (SNF) services with physical therapy and occupational therapy for treatment of the enrollees right distal radius fracture.  Findings: The physician reviewers found that the requested SNF services with physical therapy and occupational therapy were not and are not medically necessary for treatment of this patients medical condition. The documentation does not reveal that the patient requires skilled nursing or skilled rehabilitation on a daily basis or at least five days per week. The patients current functional status is at a level that she can be safely discharged to home with outpatient therapies and caregiver support if needed. The patient can transition toward a goal of an independent home exercise program. The patient has no acute, uncompensated medical issues that require a SNF level of care. She is medically stable and can follow-up as an outpatient as indicated with her providers for care including monitoring of anticoagulation, renal status, diabetic and pain management as needed. The patients current medical and rehabilitation needs can be safely met at a lower level of care. Thus, the SNF services with physical therapy and occupational therapy were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewers determined that the services at issue were not and 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Synagis injections for treatment of the enrollees hypoplastic left heart syndrome, cerebral palsy, and pulmonary hypertension. Findings:  The physician reviewer found that the use of Synagis in this patient is not medically necessary. The use of Synagis has remained under strict criteria so that its use maximizes patient benefit and efficacy while not being overused. The most widely accepted guidelines for the use of Synagis are published by the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and Bronchiolitis Guidelines Committee, and were last updated in 2014. These guidelines indicate there is no established role for RSV prophylaxis after 24 months of age for any patient regardless of any risk factors. The majority of hospitalizations that occur due to RSV are within the first three months of life and are most associated with prematurity. At this time, Synagis is only indicated in children under two years of age regardless of the presence of chronic heart, lung, or immune system disease. This prophylactic measure is not medically indicated for this patient. Therefore, the requested Synagis injections in this patient are not medically necessary. 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 pediatrics with sub-specialty certification in pediatric infectious 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.