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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees neck pain.  Findings:  The physician reviewer found that the request for acupuncture services are medically necessary for treatment of the patients medical condition. Acupuncture is clinically indicated as an adjunct to physical rehabilitation for this patient. In this case, the patient has neck pain after a cervical spine injury and is being transitioned from a hard spinal orthosis to a soft cervical collar. The patient impairment of strength is expected to limit use of self-applied modalities. Treatment with acupuncture services is medically reasonable to facilitate improvement in the patients residual musculoskeletal impairments. In addition, his comorbid conditions that include depression, anxiety, and insomnia may also improve with acupuncture. For these reasons, the requested services are considered medically necessary for the treatment of the patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee requested authorization and coverage of a NeoTect scan for the treatment of bronchoalveolar carcinoma.  The health plan denied the request, indicating that the requested scan is considered investigational for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the requested NeoTect scan is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.  Because two of the three physician reviewers concluded that the requested NeoTect scan is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Spravato intranasal spray treatment. An author noted, Treatment- resistant depression is a prevalent, disabling, and costly condition affecting 1% to 4% of the U.S. populationContinued depressive symptoms are associated with ongoing functional impairmentand a greater risk of suicide and overall increased mortality. Treatment-resistant depression is defined as failure of at least two antidepressant treatments of adequate dose and duration. In this patients case, he has been on adequate doses of both Trintellix and Remeron. He has also had a sufficient trial of Pristiq, and continues to have severe depressive symptoms. As such, he meets diagnostic criteria for treatment-resistant depression. Per the provider, genetic testing supported that Pristiq is the best fit from a gene-medication interaction. This further supports need for more aggressive treatment, as he has failed a sufficient trial of Pristiq. This patient is not a candidate for transcranial magnetic stimulation, and he has been medically cleared for Spravato. Therefore, Spravato intranasal spray treatment is medically necessary for the 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/upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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 male enrollee has requested  coverage of speech therapy for treatment of the enrollees autistic disorder. Findings:  The physician reviewer found that a recent controlled study of speech therapy in a large population of pragmatic and socially language delayed children, with and without autism, can be applied to this patient (Adams, et al.). The study reported that speech and language therapy in a population similar to this patient favorably improved language skills, as noted by teachers and parents, but did not significantly improve standardized testing of those children. The conclusion drawn by the authors is that applying standardized testing in autistic children is not a reliable test of improvement of pragmatic speech in this population. It is very difficult to meaningfully test this population of children for improvement or lack of improvement (Adams, et al.). In the case of this patient, while he has remained moderately language delayed over his two years of speech therapy, he did gain two years of language age equivalency during this therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested a magnetic resonance (MR) spectroscopy (to be performed simultaneously with a magnetic resonance imaging (MRI) study) for an evaluation of his prostate cancer. Findings:  Two physician reviewers found that the MR spectroscopy is an imaging test that has not been fully studied and as of this time is considered of unproven efficacy in this setting. The above-cited references confirm this conclusion with some studies showing no additional benefit over a standard MRI. The standard evaluation of patients with prostate cancer does not even include a MRI. Currently, MRIs are still being evaluated for reliability in establishing the extent of prostate tumor involvement in the prostate and surrounding tissue. The evidence in support of MR spectroscopy is even less convincing. As such, there is insufficient data demonstrating that the use of MR spectroscopy along with MRI is likely to confer additional benefit in this situation.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old male who is being treated with phlebotomies for hereditary hemochromatosis. The patient has developed erectile dysfunction. The Health Plan has denied authorization and coverage for treatment with Viagra because the patient is not over age 60 and because there is no evidence of hormone deficiency, neurogenic causation or vasculogenic causation. The Health Plans denial should be overturned. Treatment with a PDE5 inhibitor is medically necessary for this patient. Viagra is accepted primary therapy for the treatment of erectile dysfunction. The submitted records indicate the patient has erectile dysfunction and that use of Viagra has been effective. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollees parent has requested authorization and coverage for Aimovig. A recent presentation at the American Headache Society (AHS) discussed patients with migraine on Botox who experience end of treatment cycle wear down. The AHS noted that the addition of Aimovig boosted Botox efficacy and resulted in sustained effects in a significant proportion of patients. Combination therapy with Botox plus Aimovig utilizes different mechanisms of action, with a synergistic benefit. Although the available data are on this combination therapy is limited, the published evidence is supportive of its safety and efficacy. This patient has failed multiple standard therapies and has a contraindication to treatment with beta-blockers, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants. Given the support in the medical literature, Aimovig is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found that the requested Aimovig is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an additional 10 transcranial magnetic stimulation (TMS) treatments.  Findings:  The physician reviewer found that based on the Clinical TMS Society Consensus Review and Treatment Recommendations, the majority of patients who receive acute benefit from TMS therapy do so within four to six weeks. The meta-analysis by Berlim and colleagues indicate that the average treatment length for TMS sessions is 12.6. In this case, the patients MADRS score remained unchanged through 30 treatments of TMS. Given that the patient has had modest progress in 30 TMS sessions, it is unlikely that 10 additional TMS sessions will be of benefit. 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 psychiatry 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 acupuncture for the treatment of his stated diagnosis of hemi-facial spasm. Findings:  The physician reviewer found that the submitted clinical evidence does not provide confirmatory evidence of a specific diagnosis. The medical records discuss trigeminal neuralgia, blepharospasm, and some form of a tic.  Per the MRI, there may be an inclusion cyst that is impinging. In the absence of medical record documentation that supports a specific diagnosis and describes the treatment modalities that have been tried and failed, the medical necessity of acupuncture is not established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a consultation with a neuro-ophthalmologist. The records provided for review document that this patient developed consecutive exotropia after bilateral medial rectus muscle recessions for congenital esotropia. This is not uncommon and the provider noted that multiple surgeries may be required for management. However, the patients clinical presentation does not support an evaluation with a neuro-ophthalmologist. This patient has a condition that is commonly treated by pediatric ophthalmologists. Thus, the requested consultation with a neuro-ophthalmologist is not supported as medically necessary for further evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 ophthalmology 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 positron emission tomography (PET) scan. This patient presents with metastatic renal cell carcinoma status post right nephrectomy. Recent PET imaging demonstrated interval development of dense consolidation of paramediastinal locations of the apices. The patient has requested further evaluation with PET scan. PET is not indicated for the initial work-up of patients with renal cell carcinoma. However, this patient has advanced disease, and the requested PET scan is not part of the patients primary evaluation. The role of PET in the treatment of renal cell carcinoma can be most effective in the detection of metastatic disease, thus influencing therapeutic decisions (Liu). In addition, PET can be informative for postoperative surveillance and restaging when conventional imaging is inconclusive. Accordingly, the requested PET scan 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 PET scan is 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 3 is board certified in diagnostic radiology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Hyalgan injection to the left hipfor treatment of the his hip osteoarthritis. Findings:  The physician reviewer found that viscosupplementation is a safe and effective for treatment of pain due to osteoarthritis of the knee and temporomandibular joints. However, viscosupplementation is not U.S. Food and Drug Administration (FDA) approved for osteoarthritis of joints other than the knees and temporomandibular joints. Currently, randomized controlled clinical trials are lacking that address the effectiveness and safety of viscosupplementation of the hip. Preliminary results of small series of patients are encouraging, but further research is needed. Based on the literature and American Association of Orthopaedic Surgeons (AAOS) clinical guidelines, viscosupplementation cannot be recommended as standard treatment in hip osteoarthritis. Final Result: The reviewer determined that the requested service 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 orthopedic 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Botox injections for treatment of the enrollees cricopharyngeus dysfunction. Findings:  The physician reviewers found that In the peer-reviewed medical literature, motor events allow esophagopharyngeal air movement by promoting retrograde airflow and opening of the upper esophageal sphincter. The transport phase, possibly activated secondary to diaphragmatic contraction, consists of a retrograde contraction of the striated muscle esophagus that transports the air from the thoracic esophagus to the pharynx. The esophageal reverse peristalsis is mediated by elementary reflexes, rather than a coordinated peristaltic response like secondary peristalsis. The phases of eructation can be activated independently of one another or in a different manner to participate in physiological events other than eructation that cause gastroesophageal or esophagogastric reflux. Given these physiologic mechanisms, the Botox injections in this patients case were not anticipated to have therapeutic benefit in alleviating her described symptoms. Accordingly, the Botox injections were not likely to be more beneficial for treatment of the patient than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was 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:  Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

The patient is a 60-year-old male who was admitted to the hospital for profound depression, spurred in part by his lack of employment. He had become increasingly withdrawn, had difficulty with sleep, and had very little appetite, evidenced by a 40-pound weight loss. The patient was also reported to have expressed that he saw no reason to continue living and had considered driving his car into an abutment on the highway as a means of suicide. The admission mental status exam made note of psychomotor retardation, no eye contact, profound speech latency with monosyllabic speech, thought blocking, attendance to internal stimuli, echolalia, and nihilism. His mood was described as very depressed and his affect as nearly flat. The patient was diagnosed with major depression with psychotic features and rule out of bipolar disorder, depressed state.  From a treatment standpoint, the record indicates the patient was profoundly withdrawn, anergic, bleak and refused food, drink and medications. His sleep was grossly impaired and repeated utterances of Im sorry and crying were noted.  Given the severity of his depression, the treating psychiatrist recommended electroconvulsive therapy (ECT) and the patient, with the support of his family, agreed to undergo the treatment.  He received three bilateral-lead treatments in the hospital and the record reflects a significant improvement. Continued outpatient ECT was planned and the patient was discharged on Paxil 20mg and Risperdal 0.5mg which he agreed to take as prescribed.  The patient was severely depressed and psychotic by the time he was admitted to the hospital. Considering his age and the severity of his depression and withdrawal, ECT was the treatment of choice. This approach is consistent with the recommendations of the American Psychiatric Association for the treatment of psychotic depression. Medications alone would have resulted in a more protracted course of treatment and would have needlessly extended the patients mental and physical distress. The patient benefited significantly from the ECT therapy he received, and it is very likely the treatment will continue to be beneficial.Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested a computed tomography (CT) scan of the abdomen and pelvis for an evaluation of her abdominal pain. Findings:  The physician reviewer found that CT scans of the abdomen and pelvis are often ordered together because it is difficult to demarcate the origin of pain as being from above or below the level of the iliac crests, which is where an abdominal CT scan would usually stop. Clinically, it would make no sense to have the patient receive oral and intravenous contrast and then possibly miss the source of the patients symptoms by a few centimeters. It is widely accepted that CT scan is an excellent diagnostic test to evaluate the abdomen and pelvis. For a patient with chronic pancreatitis and prior abdominal surgeries, there could have been ascites in the dependent pelvis or adhesions affecting the bowel in the lower abdomen or upper pelvis. A myriad of other possibilities also exist. The clinicians assessment was sufficient to justify this common diagnostic procedure
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). The Health Plan has denied the bilateral breast MRI as not medically necessary.According to the American College of Radiology (ACR), the initial recommended imaging studies for evaluation of a palpable breast mass include diagnostic mammography and sonography. The specific indications for breast MRI include high-risk screening, new diagnosis of breast cancer to evaluate for additional sites of disease, patients with positive margins after lumpectomy, evaluation of response to chemotherapy prior to surgery, evaluation for breast cancer recurrence, evaluation of metastatic cancer of an unknown primary source and when mammographic or sonographic findings are inconclusive. In this case, the patient does not meet the criteria for high-risk MRI. The appropriate imaging examinations include diagnostic mammography and sonography. A diagnostic ultrasound did not identify any suspicious abnormality and the patient deferred the recommended mammogram. Therefore, bilateral breast MRI is not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested test 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 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.