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

The parent of an eight-year-old female has requested a Sleep Safer High Bed (articulated and Hi-Lo foundation version) for treatment of her cerebral palsy and developmental delay.   Findings:  The physician reviewer found that based on review of the available records, this patient has cerebral palsy with multiple complicating needs including seizure disorder, developmental delay, and autism. The patients spastic quadriplegia indicates severe motor impairment with signs of central nervous system dysfunction including seizure disorder, swallowing difficulties with gastroesophageal reflux, and risk for aspiration pneumonia. Most children with spastic quadriplegia require lifelong all-day care by the family (Dodge). A specific bed constructed to prevent entrapment and assist with positioning to help swallowing and minimize aspiration is therefore recommended. Such a bed should also have full sides with soft bumpers to minimize trauma due to the seizure disorder, positioning issues, and movement concerns. There are many beds designed for the care of the pediatric patient and it is appropriate to provide such a bed (rather than a hospital bed) for a child patient. Consistent with the providers recommendation, the requested Sleep Safer High Bed (articulated and Hi-Lo foundation version) is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compression garments. The records provided for review document that this patient established care with a hematologist following an acute deep vein thrombosis (DVT). The patients provider recommended treatment with Xarelto for three to six months as well as evaluation with multiple imaging studies to ensure DVT resolution. The patient underwent imaging as well as treatment with Xarelto, but she continued to experience pain and intermittent swelling. As part of the patients assessment, the providers diagnostic impression included post-thrombotic syndrome. The provider also recommended treatment with compression garments. Cosmi and colleagues reported that post-thrombotic syndrome is diagnosed in 40-50% of patients who are diagnosed with DVT. The authors reviewed multiple studies and reported that that thigh-length gradient compression stockings with exercise and anticoagulation are recommended for management of patients with post-thrombotic syndrome. Given this support, the requested compression garments are medically necessary for 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 physical medicine and rehabilitation with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene test. Findings:  Three physician reviewers found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases  to  regional  lymph  nodes  may  be  amenable  to  excision,  but  this  suggests  a  high  risk  for  the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma gene test has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma gene test provided was not likely to have been more effective than other methods of evaluating this patient. Final Result: 3 of 3 reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in medical oncology 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

A 36-year-old male enrollee requested authorization and coverage of the medication Nexium. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees gastroesophageal reflux disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested intravenous immune globulin (IVIG) therapy for treatment of her chronic inflammatory demyelinating polyneuropathy (CIDP).  Findings:  The physician reviewer found that a medical literature review indicates that diagnosis of CIDP is made based on history, examination, and electrodiagnostic study. The preferred therapies for CIDP include IVIG, steroids, and plasmapheresis. An evidence-based guideline from the American Academy of Neurology (AAN) states that, IVIG is effective and should be offered in the long-term treatment of chronic inflammatory demyelinating polyneuropathy (Level A). CIDP is disabling, and good results would include freedom from symptoms, and normal neurologic examination findings. This patient has had IVIG treatment, with such success that she is active, and has a normal neurological examination. Thus, continued IVIG at the doses provided should be continued to avoid the patients disease from worsening. For these reasons, the requested therapy is supported as 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 reimbursement and prospective authorization and coverage for the Botox injections for the enrollees myofascial pain and temporomandibular joint (TMJ) arthralgia. Findings:  The physician reviewers found that Botox injections significantly reduce pain in patients with myofascial pain syndrome compared with placebo. Based on the medical literature review, Botox has been shown to be the best modality for pain control after attempts of standard treatments have failed. In this case, the patient has undergone standard treatments for her myofascial pain without relief. After two treatments of Botox injections she has experienced relief of her facial spasm and relief of her bilateral jaw fatigue. Given the clinical documentation submitted for review, the Botox injections were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were and are 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 number one, two, and three are board certified in oral and maxillofacial surgery 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: Upheld

A 36-year-old male enrollee has requested Lyme disease treatment for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation includes no confirmatory evidence of any infectious disease. While it is stated that the patient has a diagnosis of Cryptosporidiosis, there is no objective documentation provided to support this diagnosis. Further, the diagnosis of CMV infection is not validated by the submitted documentation. As detailed above, all of the testing for Lyme disease was negative by standards established by the CDC. Moreover, evidence of Bartonella is not provided. All told, there is a lack of objective evidence confirming the diagnosis of Lyme disease in this patient. In the absence of such evidence, the medical necessity of the proposed treatment is not established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer.  Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature.  Therefore, breast tomosynthesis was not likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two reviewers determined that the services at issue were 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 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

The parent of a six-year-old male enrollee has requested neurofeedback (EEG biofeedback) therapy for treatment of the enrollees autism and attention deficit hyperactivity disorder (ADHD).  Findings:  Two physician reviewers found that the patient has a history of autism and ADHD and has been receiving neurofeedback for treatment. Neurofeedback makes use of QEEG analyses to assess underlying neurophysiological patterns related to the symptoms and challenges of children with autism (Coben, et al.). While the research pertaining to neurofeedback is encouraging, noting symptom improvement (Pineda, et al.), further advancements are necessary in the ongoing research area to demonstrate its efficacy. The current studies cannot demonstrate if changes observed are due only to neurofeedback treatments or other factors. Further studies are needed that are well-designed and address the issues of randomization, double-blindness, and placebo-control. Longer follow-up periods should be included in the studies to measure durability of effects. In sum, there is insufficient evidence in the medical literature to support the effectiveness of neurofeedback therapy (Rogers and Vismara).  At this time, the requested neurofeedback therapy is not likely to be more beneficial for the treatment of this patients autism and ADHD than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee has requested for individual cognitive behavioral therapy (CBT) for treatment of his obsessive-compulsive disorder (OCD). Findings:  The physician reviewer found that the records submitted for review do not demonstrate that individual CBT at the recommended intensity was or is available.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an male enrollee has requested authorization and coverage for Harvoni for 12 weeks. Findings:  The physician reviewer found that the guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test for evaluation of the enrollees invasive ductal carcinoma.  Findings:  Two physician reviewers found that Tamoxifen has to be metabolized to endoxifen, an active compound in the body. This process involves cytochrome P-450 CYP2D6 enzyme. In patients with a genetic variant that causes poor function of CYP2D6, there is concern that the patient will not receive the full benefit of the tamoxifen. There have been several attempts to evaluate this possible relationship between enzymatic activity and the effectiveness of tamoxifen. A e study of 500 women treated with adjuvant tamoxifen, and concluded that CYP2D6 assay was unlikely to be useful in clinical practice. A study reviewed six studies of this relationship and concluded that there was no clinically important association between CYP2D6 genotype and breast cancer survival in tamoxifen treated patients. One physician reviewer found that [atients with hormone receptor positive breast cancer usually receive some pharmacologic therapy to inhibit the estrogen induced growth of the cancer. Tamoxifen is the preferred agent in premenopausal patients whereas aromatase inhibitors are preferred in postmenopausal patients. This patients provider states that genotyping CYPD26 was indicated to determine tamoxifen efficacy and risk of relapse. There is some data in support of CYP2D6 testing in this clinical setting. Thus, based on the current medical literature, CYP2D6 genotyping is supported especially in premenopausal patients. Final Result: Two of three physician 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that daily left prefrontal TMS therapy has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. In this case, the patient has tried and failed multiple medications and is experiencing an acute episode of depression. Given the current medical literature and that the provider recommends TMS, the requested service is medically indicated. Therefore, TMS is medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation therapy provided over a 2 1/2 month period for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient has had a history of depression for several years. The records indicate she has stressors including marriage and family difficulties. The patient has been diagnosed with major depressive disorder, attention deficit hyperactivity disorder, and generalized anxiety disorder. She has reportedly been treated with selective serotonin reuptake inhibitors, tricyclic antidepressants, and serotonin norepinephrine reuptake inhibitors, but the details of these trials are not included in the records provided for review. The patient has also undergone psychotherapy and had prior inpatient psychiatric treatment. The patient was treated with transcranial magnetic stimulation (TMS) of the brain over a 2 1/2 month period. The patients request for reimbursement for the TMS treatment has been denied by the Health Plan, which considers the therapy at issue to be experimental and investigational. Given the records provided for review, the TMS therapy at issue was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy including medication augmentation strategies with mood stabilizers and atypical antipsychotics, psychotherapy, and consideration of electroconvulsive therapy (ECT). Although TMS has been approved by the FDA for patients with treatment refractory depression, this patients chart does not demonstrate that her condition was refractory during the period of time she received TMS therapy. Additionally, the peer-reviewed medical literature suggests that ECT remains the most effective form of therapy and remains the gold standard. Thus, despite concern for potential side effects associated with ECT, as noted by Slotema and colleagues, ECT provided superior results in the treatment of patients with depression. Although some studies indicate that monotherapy with repetitive TMS was more effective than repetitive TMS as adjunctive to antidepressant therapy, ECT was superior to repetitive TMS in the treatment of depression (Slotema, et al). Consistent with these findings, the therapy at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old woman who underwent right total knee replacement in April 2005 due to osteoarthritis. Postoperatively, she developed arthrofibrosis with range of motion limited to 88 degrees; joint manipulation was performed under general anesthetic in June 2006. The continuous passive motion (CPM) machine along with physical therapy was prescribed by her orthopedic surgeon following the manipulation to maintain her range of motion. The patient is now requesting reimbursement for the rental cost of the device. The Health Plan denied her request based upon their determination that the CPM machine was not medically necessary following the patients right knee manipulation. A CPM device is the standard of care for postoperative rehabilitation following knee replacement. Patient compliance is high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. In this case, the CPM machine was also prescribed to preserve the patients range of motion following manipulation of the knee. Mobilization of the joint was imperative for a patient such as this one to avoid loss of motion and the need for additional manipulation in the future. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient is requesting authorization and coverage of Vivitrol 380 mg vial. Findings:  The physician reviewer found that the patient reportedly began treatment with injectable naltrexone. It was noted treatment with naltrexone has been successful. The patient was noted to have maintained his sobriety. At issue in this case is whether Vivitrol 380mg vial is medically necessary for the treatment of this patients medical condition. Vivitrol is indicated for the treatment of alcohol dependence. A study reported that shortterm treatment with Vivitrol has been shown to decrease the chance of alcohol relapses by 36% and is likely to reduce the chance of returning to drinking by 13%. In addition, the authors found that Vivitrol lowered the risk of withdrawal in 28% of alcoholdependent patients. Naltrexone is an effective and safe strategy in alcoholism treatment. This patient has documented benefit from treatment with injectable naltrexone and has maintained abstinence from alcohol for five months. Therefore, Vivitrol 380mg vial is medically necessary for 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 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: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for radiofrequency ablation of the esophagus for treatment of his Barretts esophagus. Findings:  Three physician reviewers found that there is a lack of randomized, controlled trials supporting radiofrequency ablation of the esophagus in this case.  Based upon the documentation, there is no evidence of dysplasia. As noted by the American Gastroenterological Association, the current medical evidence does not demonstrate that endoscopic eradication therapy, including radiofrequency ablation, is more effective at reducing cancer risk than long-term surveillance in patients with Barretts esophagus in the absence of dysplasia. The current data does not show that radiofrequency ablation has any added benefit beyond continued surveillance in this clinical situation.  Thus, the requested radiofrequency ablation of the esophagus is not likely to be more effective than other available treatment options in this patients case.