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

The patient is a 45-year-old female with a history of recurrent endometrial polyps that cause her to have menorrhagia. The patient and her physician wish to have a Mirena IUD placed to prevent the endometrial polyps from returning. The Health Plan indicates the Mirena IUD is only FDA approved for contraception, and has not been approved for treatment of endometrial polyps. Therefore, the Health Plan has denied coverage for the requested device. The Mirena IUD is only FDA approved for contraception and is not FDA approved for treatment of menorrhagia or endometrial polyps. Though there are several published articles showing that the Mirena IUD can be an effective treatment for menorrhagia, there are no articles demonstrating that the device is effective for the prevention of endometrial polyps. In fact, several articles studying menorrhagia excluded patients with endometrial polyps. In one study of 14 patients there were two failures, one because of an endometrial polyp and one because of a submucosal myoma. Another study showed that the Mirena IUD was less effective for the treatment of menorrhagia when the patient had uterine myomas. Off-label use of an approved device requires clear evidence of the effectiveness of the proposed use. To date, there are no studies showing the Mirena IUD is effective for treatment of endometrial polyps. Therefore, I have determined that the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether for the Optune device that was rented was likely to have been more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Three physician reviewers found that a review of the record indicates that the patient presented to the emergency department with complaints of a headache associated with dizziness, nausea, vomiting, photophobia and fatigue. He underwent radiographic imaging that revealed a large frontal mass on the right side with swelling and compression noted. The patient was diagnosed with glioblastoma multiforme. He subsequently underwent a craniotomy followed by chemo-radiation treatment.The medical literature supports the use of an Optune device for the treatment of glioblastoma. The National Comprehensive Cancer Network (NCCN) guidelines include an Optune device as a treatment option for patients as adjuvant therapy. The U.S. Food and Drug Administration (FDA) has approved Optune. Current evidence supports the use of TTFs as an efficacious, antimitotic treatment with minimal toxicity in patients with newly diagnosed and recurrent GBM.Final Result: Three out of the three reviewers determined that the requested device was likely to have been 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 internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral reduction mammaplasty. The American Society of Plastic Surgeons (ASPS) states that reduction mammaplasty is supported for patients with severe symptoms of macromastia and evidence of reduced health-related quality of life. This patient presents with upper back, neck and shoulder pain. She has clinical findings of shoulder grooving from bra straps documented on physical examination. The patient reports intertrigo underneath her breasts, but the records do not support that the intertrigo has been unresponsive to medical management. She reports headaches, but this is not specific to breast hypertrophy in the absence of further clinical information. On review, this patient has severe symptoms of macromastia and at least two decreased quality of life signs. Per ASPS criteria, the requested bilateral reduction mammaplasty is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The available records support the presence of bilateral breast hypertrophy, which is a developmental deformity. The provider noted that the patients condition is causing pain, which is impairing the patients ability to function. The appearance of ptotic breasts is within normal limits for the patients age and weight. The California reconstructive surgery statute supports the requested bilateral reduction mammaplasty for this patient due to the presence of a developmental deformity that is causing her functional impairment. Accordingly, the requested bilateral reduction mammaplasty is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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: Upheld

SummaryThe patient is a 34-year-old woman with chronic headache associated with neck muscle pain and spasm. She is requesting authorization for Botox therapy.  The Health Plan has denied authorization for Botox indicating it is not medically necessary.  The physician reviewer concluded that the Health Plan denial should be upheld.  Analysis and FindingsClinical Facts:  The patient has chronic headache associated with neck muscle pain and spasm. She is requesting authorization for Botox therapy. The patient has consistently refused usual migraine preventive therapy. MRIs of the brain and neck were unremarkable. An EMG reported cervical muscle spasm consistent with dystonia.  Reviewers Findings:The reviewer found that although Botox is beneficial for some patients with intractable migraines, it is not appropriate as a first or second line therapy for this condition. Additionally, while Botox is FDA approved and clinically indicated for cervical dystonia, the presence of cervical spasm alone is not sufficient to support a diagnosis of cervical dystonia. The patients history and neurologic examination do not support a diagnosis of cervical dystonia. Furthermore, EMG testing cannot establish or confirm a diagnosis of cervical dystonia. All told, the patient has not exhausted conventional therapies for treatment of her headaches and neck pain and is not an appropriate candidate for Botox at this time.  Therefore, the reviewer found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee requested authorization and coverage of botox injections for the treatment of leg pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that botox injections are not likely to be more beneficial for treatment of the enrollees leg pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the genotype testing performed. Findings:  The physician reviewer found that The documentation provided does not demonstrate that the genotype testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patients records do not specify medications, doses, and length of medication trials or combinations of medications tried and failed. The records do not indicate that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence based psychotherapy trials. In addition, it is not clear that the patient has had cognitive behavioral therapy (CBT) for her anxiety disorder diagnosis. As noted in the peer-reviewed medical literature, CBT is considered the first-line treatment for this patients condition and has years of evidence to support its use. Medication and psychotherapy have strong evidence based support for their use in the patients condition and it is not clear that these treatments have been exhausted. The current evidence base does not support the routine use of pharmacogenomic testing in this clinical setting. For these reasons, the genotype testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition Credentials/Qualifications: All three physician reviewers are  board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 29-year-old female who underwent arthroscopic surgery on her left knee in July 2005. A cold therapy unit was utilized postoperatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful postoperatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the device following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient level of care provided. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on review of the available records, the acute inpatient services were medically necessary from the dates at issue. This patient already had two prior inpatient psychiatric admissions within the previous six months of this admission. The providers notes indicate the patients diagnosis was questioned and his previous treatment with Risperdal, Depakote and lithium was changed. The provider also noted that the patients behavior was cooperative on the unit which was a sharp contrast to the description of his aggressive and uncontrollable behavior at home. The treatment course was to discontinue all of the patients current medications and start him on a different course with Concerta to address any untreated symptoms associated with ADHD. Thus, the inpatient treatment for the dates at issue was clinically indicated as abruptly discontinuing the patient from his current regimen could have precipitated a significant reaction in terms of acute deterioration in function as well as withdrawal symptoms. Further, the difference in the patients behavior on the unit versus at home required observation outside the home to separate the psychiatric component of the patients illness from his contributing family situation. The providers needed skilled observers to record the patients behaviors on the unit to compare them with the described behaviors at home. For these reasons, the acute inpatient services provided for the dates at issue were medically necessary for management of the patients medical condition. As the patients records end at discharge, there is inadequate documentation available to support the medical necessity of acute inpatient services beyond the discharge date.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the computer-assisted musculoskeletal surgical navigation system used during knee replacement surgery for treatment of the enrollees left total knee arthroplasty. Findings:  Two physician reviewers found that there is sufficient support in the peer-reviewed literature for the service at issue in this clinical setting. The study analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry to examine the effect of computer navigation on the rate of revision of primary total knee arthroplasty. The authors concluded that Computer navigation reduced the overall rate of revision and the rate revision for loosening/lysis following total knee arthroplasty in patients less than sixty-five years of age. Thus, the use of computer navigation in total knee arthroplasty when utilized by a surgeon skilled in the use of that technology is likely to be beneficial, particularly in a patient younger than 65 years of age. For the reasons provided, the computer-assisted musculoskeletal surgical navigation system used during knee replacement surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: the reviewers determined that the service at issue was 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: Reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 test. Findings:  Two of the three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care for stage III and IV disease. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Thus, Guardant360 test was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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 63-year-old male enrollee requested a series of five Supartz injections to the left knee for medical treatment of the enrollees left knee osteoarthritis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons guidelines for the treatment of osteoarthritis of the knee state, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an endoscopic lumbar sympathectomy for treatment of her medical condition.   Findings:  Two physician reviewers found that there are a number of recent articles in the peer-reviewed literature that suggest or show excellent outcomes for patients with plantar hyperhidrosis following endoscopic lumbar hyperhidrosis. These articles also show sustained benefit in these same patients without a need for further surgery or procedures. The overall goal of intervention in this patient is to achieve sustained, lasting benefit combined with the lowest possible risk. Per the records, standard treatments have failed. Therefore, it is highly likely that endoscopic lumbar sympathectomy will provide successful, clinically relevant, sustained relief of this patients hyperhidrosis. In sum, the requested procedure is likely to be more effective than any standard available treatment options for this patient. Final Result: Two reviewers determined that the requested procedure 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:  One reviewer is board certified in neurological surgery and is actively practicing. Two reviewers are board certified in dermatology 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: Medical Necessity
Decision: Upheld

The patient is a 20-year-old man who sustained a traumatic brain injury in a motor vehicle accident. The patient received inpatient rehabilitation services following the accident. In July 2003, the patient was transitioned to a program, which provided physical therapy, occupational therapy, speech and language pathology, and neuropsychology in the home setting. The patient continued to receive these services until 12/3/03. The Health Plan indicates that such services were not medically necessary after 8/21/03.  As of 8/21/03, the patient was functioning with limited supervision in the home and was able to perform strength exercises and to play basketball with supervision. Although the patient continued to have some cognitive deficits, he was progressing well. There is no evidence to demonstrate that comprehensive rehabilitation services were required after 8/21/03; the patient had achieved a level of functioning that no longer required comprehensive rehabilitation services. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested for therapeutic apheresis for treatment of his tendinosis.   Findings:  Three physician reviewers found that the use of platelet-rich plasma injections for this patient is not likely to be more beneficial than standard therapies. One reason for this is the non-specificity of this patients diagnosis. The MRI findings of pathologies other than just hamstring tendinosis suggest that it is unlikely that treatment with platelet-rich plasma injections would eliminate significant contributing pain generators. In addition to the patients right hamstring pathology, the presence of similar changes in the patients opposite left hamstring origin (which is presently asymptomatic) also diminishes the likelihood that there would be an effective treatment response to platelet-rich plasma injections. The orthopedic literature is not supportive of the requested therapy at this time. While this is a promising area for future treatment protocols, to date there have not been sufficient studies to demonstrate the efficacy of platelet-rich plasma injections in this setting.