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

A 33-year-old female enrollee has requested residential treatment services for treatment of her alcohol dependence and major depressive disorder. Findings:  The physician reviewer found the submitted medical records support the medical necessity of the services at issue.  Per the American Psychiatric Association, residential treatment may be indicated for patients whose social interactions focus exclusively on substance use and who lack motivation or substance-free supports to remain abstinent in an ambulatory setting.  In this patients case, the diagnosis of major depressive disorder was a concerning comorbidity.  Despite outpatient psychiatric treatment, the patient was drinking excessive quantities of alcohol.  Her alcohol consumption was dominating her functionality.  Per the medical records, the patient lacked adequate social supports to achieve sustained recovery.  The current medical evidence supports the services at issue in this setting.  All told, residential treatment services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck. According to the American College of Radiology (ACR), MRI of the cervical spine is usually appropriate for the evaluation of patients with new or increasing nontraumatic cervical radiculopathy, or in the setting of known malignancy. In addition, MRI is the optimal examination for the evaluation of intervertebral discs, facet arthropathy, foraminal stenosis, nerve root compression, and spinal stenosis. In this case, the patient underwent evaluation with prior radiographs of the cervical spine, which demonstrated spondylosis at multiple levels. The patient also has a personal history of breast cancer and there is concern for metastatic disease given her nontraumatic neck pain. The results of the MRI could change clinical management including surgical or medical interventions. MRI is currently the preferred modality to evaluate the cervical spine in the setting of this patients nerve root impingement. Given these findings, the requested MRI of the neck is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Upheld

The patient is a 58-year-old male who has been managed by a dermatologist for psoriasis, which is apparently significant in both severity and extent of involvement. In addition, he has been treated with Enbrel with major benefit for his cutaneous disease. His dermatologist has requested authorization and coverage for continued Enbrel treatment for the patients psoriatic arthritis. The Health Plan has denied this request indicating the requested medication is not medically necessary for the patients medical condition.Review of the submitted records indicates the patient has psoriasis. There is no confirmation of a diagnosis of psoriatic arthritis or evidence that the patient has been examined by a rheumatologist. Thus, the nature of prior treatment is unclear. It is not known if the patient has received an adequate trial of methotrexate. Additional follow-up is needed to determine if the patient has significant arthritis. If so, the patient should undergo a rheumatologic evaluation to decide which type of arthritis is present (whether psoriatic or otherwise) and what treatment would then be appropriate. Based upon the information provided, there is no medical justification for continued use of Enbrel at this time. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female has requested MammaPrint gene expression testing for evaluation of invasive ductal carcinoma.  Findings:  Two physician reviewers found that the patient was found to have an ER+, PR+, HER2 negative 7 mm infiltrating ductal carcinoma with a 0.45 micrometastasis in one lymph node. Her provider ordered a MammaPrint genetic expression test which he indicated was necessary to estimate the patients prognosis.  The FDA has approved the use of the MammaPrint gene expression test. The Centers for Medicare and Medicaid Services (CMS) guidelines recognize a clinical indication for MammaPrint in patients with small tumors node negative or positive up to three nodes, micrometastasis, and Tamoxifen independence. The MammaPrint and Oncotype Dx provide similar predictions of clinical outcome. From a clinical standpoint, the MammaPrint genetic expression test has significant value in this patient and is likely to provide greater benefit than standard testing.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested a virtual colonoscopy procedure for an evaluation of his colon. Findings:  Two physician reviewers found that colonoscopies and barium enema are the first and second-line procedures used to screen for colorectal cancer. Having failed these two methods, likely due to significant diverticulosis, a virtual colonoscopy is an appropriate alternative. With this technology, the CT scan can also look at the structures extrinsic to the bowel to help explain the difficulty with the initial procedures and to look for possible lesions outside of the bowel wall. Research has found that the sensitivity of virtual colonoscopy approaches that of colonoscopy, especially for polyps larger than 1 cm.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a six-year-old female enrollee has requested a positron emission tomography (PET) and/or a single photon emission computed tomography (SPECT) scan for an evaluation of the enrollees medical condition. Findings:  Two physician reviewers found that both PET and SPECT scans are routinely used to help evaluate patients with intractable temporal lobe epilepsy (TLE) who may need surgical resection of diseased brain tissue. SPECT scans have less utility than PET scans because of the relatively low temporal resolution and the frequent detection of both ictal onset zones and propagation pathways (which may still represent viable brain tissue). This patient, while potentially having historical features of TLE, has not met the criteria for intractable TLE. However, in a 2008 study by Boling and colleagues, it was shown that a careful, structural MRI with volume measurements of mesial temporal structures could clearly demonstrate atrophy, but when used in conjunction with fluorodeoxyglucose PET scanning, was superior in identifying patients with TLE. Thus, the use of PET, but not SPECT, is warranted to evaluate this patient and to help identify whether her episodes represent TLE, which would in turn argue for treatment with appropriate anti-epileptic drug therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clonazepam 0.5 mg daily. Although the requested dose of clonazepam is low, two of the patients providers have recommended that the patient be weaned off clonazepam. The recommendation to wean the patient off clonazepam in this clinical setting is consistent with the medical literature. Long-term treatment with benzodiazepines is not recommended in patients over 64 years of age, given the potential risks, including cognitive impairment, falls, respiratory problems, and dependence. This patient reports that clonazepam has been beneficial in managing his insomnia. However, the records provided for review do not include a sleep study fully evaluating the patients symptoms of insomnia. In addition, there is no report that the patient has been treated with doxepin. One of the patients providers recommended cognitive behavioral therapy (CBT), which is considered first-line therapy in the treatment of insomnia and is likely to be effective for this patient. For these reasons, the requested clonazepam 0.5 mg 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 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 a two-year-old male enrollee has requested individual speech and language therapy in English and Vietnamese for a total of two hours per week for treatment of the enrollees language delay.  Findings:  The physician reviewer found that children with speech delays, including those with cognitive delays, are candidates for successful speech therapy (Goorhuis-Brouwer & Kniff).  Two-year olds who tested below the 10th percentile, such as this patient, do require and benefit from speech therapy (Emanuel, et al. and Buschman, et al.). In this case, speech therapy has been requested in English and Vietnamese. As the patient is not currently speaking, it would be most beneficial from a clinical standpoint to have him participate in only English-speaking speech therapy at this time. However, if his parents ability to speak English is limited, their ability to participate as co-therapists is hampered and a bilingual therapist will be needed to treat the patient in English and communicate with the parents in Vietnamese.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of surgical removal of three sebaceous facial cysts. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees facial cysts.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 70-year-old female enrollee has requested computed tomography (CT) to detect coronary artery calcification performed for evaluation of her medical condition. Findings:  Two physician reviewers found that based on the records provided, this patient has a history of atrial fibrillation, dyslipidemia, no other coronary risk factors, and no documented coronary disease. In this circumstance, CT screening for coronary calcium was not indicated. Current guidelines for management of dyslipidemia endorsed by several national organizations do not recommend routine CT screening for coronary calcium because there is a lack of data to suggest that a change in treatment based on the results leads to improved outcomes incremental to those achievable using standard risk factor profiling (see NCEP ATP III). The only circumstance where CT screening for coronary calcium may provide superior data is in a patient with intermediate cardiac risk (10-20% 10-year risk) in whom a decision to treat with cholesterol medication is uncertain based on standard clinical risk profiling alone (see Greenland and colleagues). However, based on the submitted records, this patient did not have an intermediate cardiac risk.I have determined the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested orthotics for treatment of the enrollees flat feet.  Findings: The physician reviewer found that the submitted documentation supports the requested equipment in this clinical setting.  Flat foot can be divided into two general categories, flexible and rigid.  In flexible flat foot, the collapsed arch is present only when the patient bears weight.  In rigid flat foot, the arch is fixed in position regardless of weight-bearing status.  Most of the time, flexible flat foot is asymptomatic and requires no treatment. However, according to the literature, symptomatic flat foot requires treatment.  Options include activity modification, proper shoes and orthoses, stretching and strengthening exercises, and non-steroidal anti-inflammatory medications.  Surgery may be considered if all other treatment options fail.  In this patients case, she has multiple medical problems as a result of and in addition to her chromosomal disorder, and she has muscle weakness and gait characterized by in-toeing.  She has been diagnosed with flexible pes planus with collapsed medial arch bilaterally, and she has been prescribed custom orthotics to offer improvement in gait and stability.  Based on the current literature, the requested orthotics are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 pediatrics 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for applied behavior analysis (ABA) assessment and/or therapy services. The ABA Coding Coalition has endorsed ABA therapy for patients with mild intellectual disability and/or ADHD. The Coalition noted that, When designed and overseen by qualified professionals, ABA treatments have proved effective for ameliorating symptoms, developing adaptive behaviors, and reducing maladaptive behaviors so as to enhance healthy, successful functioning and prevent deterioration and regression in patients with disorders that arise during the developmental period. Considering this patients behavioral issues, the requested evaluation to determine the focus and ABA treatment plan is medically necessary. In addition, ABA therapy is a recommended strategy to treat ADHD as identified by the Centers for Disease Control and Prevention (CDC). Caye and colleagues recommend that preschool aged patients should start with ABA therapy due to the potential safety concerns of starting medication at a young age. The CDC suggests ABA therapy, including parent training to help manage behavior, as one of two effective strategies to treat ADHD. Given this patients presenting behavioral issues, the requested ABA therapy with an emphasis on parent training is medically necessary. To adequately determine the intensity and scope of ABA treatment plan, the requested assessment must first be completed. Moreover, the requested ABA evaluation and therapy are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested ABA assessment and therapy services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia injection (denosumab) 1 mg 60 units every six months. Findings:  The physician reviewer found that The records provided for review document that this patient has a history of osteoporosis that has worsened over time. The patients provider has recommended treatment with Prolia. Over the past few years, the number of treatment options for the management of osteoporosis has grown significantly (Khosla and Hofbauer). Of the medications developed, the most potent antiresorptive agent is Prolia. In a large, randomized placebo-controlled trial of 7,868 postmenopausal female patients with osteoporosis, biannual 60 mg subcutaneous Prolia injections were able to increase bone mineral density (BMD) by 9.2% in the spine and 6.0% in the hip when compared to placebo (Lorentzon). Prolia is indicated as therapy for postmenopausal female patients with osteoporosis who are at high risk for fracture. In addition to this patients worsening osteoporosis, she has a history of spine problems which have required surgery. In this clinical setting, the medical literature supports treatment with Prolia for this patients osteoporosis and elevated fracture risk. All told, the requested Prolia injection (denosumab) 1 mg 60 units every six months 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested continued use of Xolair for treatment of his asthma.  Findings:  Two physician reviewers found that the patient has received steroid therapy and rescue inhaler prior to beginning Xolair.  Since starting Xolair, the patient no longer requires rescue albuterol or inhaled corticosteroids. On the said date, the medical records noted that patient continued to have occasional symptoms, although he had improved and was doing well on Xolair. The submitted documentation notes a reduction in the number of acute asthma exacerbations requiring oral corticosteroids, a reduction in the use of inhaled corticosteroids, a reduction in the use of beta agonists and an increase in quality of life.  The patient has requested coverage for continued use of Xolair.  In this patients case, continued use of Xolair is likely to be more beneficial than other available treatment options. The patient is now well-controlled on Xolair therapy. This patient has a persisting mild obstruction of flows, as noted in current pulmonary function testing. In this case, continued use of Xolair is consistent with standards of good medical practice. The submitted records indicate a good response to Xolair therapy, with improvement of all parameters and reduction in the use of medications.  Therefore, continued use of Xolair is likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injection of the left knee for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of knee replacement.  In this case, the patient presents with debilitating left knee pain impairing her ability to walk and be active.  Clinical examination findings are consistent with radiographic evidence of left patellofemoral arthritis.  There is evidence of significant prior benefit with viscosupplementation that allowed for sustained improvement in her functional mobility.  She is currently not a surgical candidate. Therefore, the requested Synvisc injection of the left knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.