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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. 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: Reviewers 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: The patient has a history of opioid dependence, alcohol dependence, cannabis dependence, cocaine dependence, autistic disorder and borderline personality disorder. The patient was admitted to a residential treatment center (RTC) on 8/13/18. The patient was trying to stop heroin without medical assistance, with fear of relapse. The records document that the patient had passive suicidal thoughts, but denied homicidal thoughts, and did not exhibit any psychosis. At the time of admission, the patient was living with their partner. The records report that the patient has a history of four suicide attempts in the past. At issue is whether the residential treatment services that received from 9/10/18 to 10/1/18 were medically necessary to treat this patients medical condition. The American Society of Addiction Medicine (ASAM) criteria proposes six domains that must be met to qualify for residential treatment admission. For an adult, they must meet all six domains to qualify. These domains include: acute intoxication; biomedical conditions, emotional, behavioral cognitive condition; readiness to change; relapse, continued use or continued problem potential; and recovery environment. The patient was exhibiting some anxiety and some passive suicidal thoughts. However, the patient was not showing any medical instability. He demonstrated decreased cravings and struggled with group activities. The patients drug screen was positive for Suboxone. The patient was not showing any withdrawal or any risk for acute or subacute withdrawal. The patient had no biomedical condition that distracted recovery and he did not have any emotional, behavioral or cognitive conditions requiring the RTC level of care. The patient was motivated to change and revealed insight into his condition. The patient did have relapse triggers but was not in any imminent danger or crisis situation. The patient was in a recovery environment that was not considered unsafe but supportive. Utilizing the ASAM criteria, this patient met the criteria for outpatient treatment. Therefore, the RTC services provided from 9/10/18 through 10/1/18 were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Nutropin AQ Nuspin. He was born at 36 gestational weeks and his birth weight was 1880 grams (gm). The cut off for SGA at 36 weeks is 1889gm/43.8 centimeters per year. There was no catch-up growth since birth. He was started on growth hormone (GH) therapy in January 2020. His pretreatment height velocity is reported to have been 7 centimeters per year. His height velocity on GH therapy is reported to be 10 centimeters per year. GH for the treatment of children who are SGA and who fail to exhibit catch-up growth is the standard of care. This indication has approval from the FDA, support from consensus guidelines, and randomized controlled trial evidence to support its use. The patient appears to have failed to catch-up with a height more than 2 SDS below the mean. GH therapy for this patient is consistent with accepted standards of medical practice. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing should not be an impediment to coverage, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series in the right knee now and repeated in six (6) months.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a long history of benefit from prior injections which lasted 6 months each time. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, the requested Orthovisc injection series in the right knee now and repeated in six (6) months is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Enrollee has requested authorization and coverage for Spinraza. The Health Plan has denied this request indicating that the requested medication for treatment of the enrollees spinal muscular atrophy (SMA).  Findings:  Three physician reviewers found that Spinraza is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Chiriboga reviewed published studies of Spinraza for the treatment of SMA. The author states that The studies show improvement in motor function across SMA of all types, including SMA type 3. The author further notes that Spinraza was found to be safe and well tolerated across all age groups studied. The author concluded that Spinraza should be considered as standard of care for the treatment of SMA of all types.  Moreover, Spinraza is U.S. Food and Drug Administration (FDA) approved for treatment of SMA. For the reasons provided, the request for Spinraza 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 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for Botox injections every three months. The records document that this patient presents with a medical history significant for term forceps delivery and torticollis noted at several months of age. He was treated with physical therapy and a cranial orthosis for plagiocephaly, with significant improvement in head shape. The patient has been started on a regimen of Botox injections. Botox has been used for patients with torticollis when more conservative measures such as repositioning, cranial orthoses, and physical therapy have failed to correct muscular torticollis (Qiu, et al.; Bourseul, et al.). In this case, the patient has failed treatment with months of physical therapy, repositioning, and use of a cranial orthotic. The patients torticollis is negatively impacting his ability to fully develop age-appropriate skills. For these reasons, Botox injections every three months as needed were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 pediatrics with subspecialty certification in pediatric critical care and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested high intensity focused ultrasound (HIFU for treatment of the enrollees prostate cancer.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. HIFU consists of focused ultrasound waves, emitted from a transducer that causes tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU is to heat malignant tissues above 65C so that they are destroyed by coagulative necrosis. However, the available literature mainly consists of prospective case series and retrospective studies from Europe showing short to intermediate term outcomes for localized prostate cancer. Controlled trials and long-term survival data for the requested services are lacking. Moreover, validated biochemical and surrogate end-point for cure of patients who have undergone HIFU are also deficient. The National Comprehensive Cancer Network (Guideline Version 1.2015) panel states that focal therapy and HIFU warrant further study. In this clinical setting, there are other available methods of treatment. As such, the requested authorization and coverage for HIFU is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee requested rituximab 1 gm x 2, 15 days apart for medical treatment of her C1q nephropathy with arteriolar sclerosis.  Findings:  The physician reviewer found that C1q deposits in the mesangium occur with minimal change disease, focal segmental sclerosis, and immune complex glomerular nephropathy. There is currently a lack of randomized controlled clinical trials to guide therapy, which is usually directed at the light microscopic pattern of injury. However, there is data demonstrating successful outcomes with use of rituximab in this clinical setting. Further, rituximab does not appear to be inferior to steroids and cyclophosphamide in terms of safety and efficacy for treatment of C1q nephropathy. Given these findings, the requested rituximab 1 gm x 2, 15 days apart is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old male enrollee requested authorization and coverage of services from a non-contracted provider  for the treatment of mucinous adenocarcinoma of the abdomen.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Opana ER for treatment of her medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has a chronic pain diagnosis, which has been treated with a number of modalities, and multiple narcotic and non-narcotic pain medications. Researchers report that for chronic non-cancer pain, short and long acting opioid has been found to be effective. The authors also suggested that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In this case, the patient has failed treatment with some medications, and could not tolerate some others. The patients provider has also recommended non-pharmacological therapies. However, given the patients uncontrolled pain, she will not likely be able to perform the recommended therapies. In this clinical setting, a trial of Opana ER is medically necessary to allow the provider to document patient outcome in terms of improvement of function and possible decrease in short-acting narcotic use.  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 anesthesiology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has a history of osteoarthritis of the left knee and associated pain. The patient has tried ibuprofen, bracing, physical therapy, acupuncture, and corticosteroid injections which no longer work. However, he benefitted from viscosupplementation injections provided previously. The provider has recommended a series of Euflexxa injections (J7323) for left knee. At issue is whether a series of Euflexxa injections (J7323) for left knee is medically necessary for the treatment of this patient. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of benefit from viscosupplementation injections to the left knee provided. Furthermore, prior treatment with physical therapy, bracing, acupuncture, ibuprofen and corticosteroid injections were not effective. In this clinical setting, the requested series of Euflexxa injections (J7323) for left knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested service 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 orthopaedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested speech therapy and occupational therapy services for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that the scientific literature supports speech therapy in the treatment of autistic children. People with autism spectrum disorders often have deficits in communication and treatment by a speech therapist is usually appropriate, as most children with autism spectrum disorders can develop useful speech (Myers, et al.). Children who have received speech therapy had far greater communication skills than those that did not participate in speech therapy (Turner, et al.). However, the literature which supports speech therapy for autistic children is not applicable to this patient. There is strong scientific evidence supporting the use of occupational therapy in the treatment of autistic children. Occupational therapy is effective in reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al.). May-Benson and Koomar performed a meta-analysis regarding the use of sensory integration techniques in the treatment of autistic children and concluded that sensory integration was effective. Therefore, occupational therapy could improve this patients self-help and play skills within a group setting. Based upon the documentation provided, occupational therapy is a medically necessary modality for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of a spiral CT scan and an EBCT scan. The Health Plan denied the request indicating that the requested services are not medically necessary for evaluation of the enrollee.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.