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

A 46-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her breast cancer, pancreatic cancer, and McCune-Albright syndrome.  Findings:  Two physician reviewers found that this patient has a history of two prior malignancies as well as a third condition known to have increased risk for a third malignant process. The metallic devices render conventional imaging limited due to artifact. Careful imaging follow-up is required and PET would be the best procedure for surveillance. The PET scan provides the anatomic imaging necessary and facilitates physiologic analysis of all organ systems to detect increased metabolic activity which would indicate a high probability of tumor. No other imaging technique allows for such anatomic and physiologic analysis. Consistent with these findings, the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested  psychiatric residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient's primary issue is substanse abuse. However, he also has a diagnosis of ADHD. He was tried on a few medications, but based on the information provided, has not been under regular psychiatric management.  He had a few short stints of outpatient therapy as well. The records do not document any treatment in a partial day hospital program or an intensive outpatient program. His treatment at the wilderness program only involved weekly therapy. Overall, the patient has not had adequate trials of less intensive therapy to address his mental health issues. While some of the enrollees providers suggested that his substance/oppositional issues were related to poor family relationships, there is no documentation that adequate trials of family therapy were undertaken. Based on the records from the patient's residential treatment stay his need for psychiatric monitoring was minimal and his medication regimen was uncomplicated ( and only for the treatment of his ADHD). This patient was not very engaged in treatment and was often described as uninterested. The submitted documentation does not clearly demonstrate that family functioning was improving in treatment, which is a vital aspect of successful treatment (Green and colleagues). There is also little evidence-based literature to support that RTC treatment is superior to less restrictive forms of treatment (McCurdy and McIntyre). In conclusion, the medical necessity of the patient's past and present treatment at a psychiatric residential treatment level of care has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for cyclosporine 2% compounded with ophthalmic drops. The Health Plan has denied this request indicating that the requested compounded medication is considered investigational for treatment of the patients chronic bilateral Thygeson's superficial punctate keratitis (TSPK). Findings:  The requested compounded medication is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. In this patients case, the treatment of Thygesons SPK with cyclosporine is not more beneficial than any available standard therapy, based on the efficacy and availability of topical steroids, (the standard of care), and the lack of evidence that cyclosporine 1% is safe and effective for this patients condition. There are no controlled studies in the medical literature with sufficient numbers of treated patients to show that cyclosporine is a viable alternative to steroid treatment for patients with Thygesons. Therefore, cyclosporine 2% compounded with ophthalmic drops are not 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 compounded medication is 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/QualificationsAll three reviewers are board certified in ophthalmology 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 four-year-old male who has been diagnosed with autism, sensory processing problems, delays in self-care/feeding problems, and delays in fine motor/adaptive skills. The patient has been receiving occupational therapy since March 2003. A request has been made for continuing occupational therapy including sensory integration therapy one time per week for six months. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary.Autism is a complex, difficult disease. Responses are at times in small increments. There are many treatment modalities, but few are universally accepted. Occupational treatment including a sensory integration component is a reasonable treatment approach for this patient. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive occupational therapy including sensory integration therapy once a week for a three-month period with transition to a home program at the end of the three-month period.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support cited above, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue 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: All three physician 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for steroid injections.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has symptoms of lumbar radiculopathy. Per the records, MRI demonstrated a caudally extruded right paracentral disc herniation abutting the right S1 nerve root as well as degenerative changes in other lumbar discs and facet arthropathy.  She has had trials of conservative therapy which have not improved her pain. The injections  provided produced 70% pain relief. The medical evidence supports epidural steroid injections in this patients case. Clinical practice guidelines support performing an epidural steroid injection in the presence of lumbar radiculopathy where prior injections have been documented to provide 50% pain relief for a significant period of time, as in this case.  Therefore, the requested steroid injections are medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician 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

The parent of a 13-year-old male enrollee has requested the medication Intuniv for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that this patient reportedly experiences severe side-effects from stimulant medications and Strattera. However, his provider reports he has done well on guanfacine XR (Intuniv) and would like to continue on this medication. There is strong literature to support the fact that 80-90% of patients respond to stimulant medications (Pliszka).  However,  side effects can be intolerable. These side-effects are unfortunate and well-documented (Biederman), Although stimulant therapy has been the mainstay of ADHD treatment, some subjects do not respond to stimulants or are unable to tolerate the associated side effects. There are other alternatives to stimulants and Strattera, such as bupropion and tricyclic anti-depressants, however these medications do not have FDA-approval for this indication and are often not efficacious (Pliszka). Intuniv is an FDA-approved treatment for ADHD whereas guanfacine is not. As noted by Kratochvil, As of September of 2009, guanfacine in XR form is the first alpha(2)-adrenoceptor agonist to gain approval to treat ADHD, approved for the treatment of 6- to 17-year olds. In addition, Biederman indicates, A recent double-blind, multi-center trial supports the efficacy and safety of guanfacine extended release (GXR) for pediatric ADHD. This long-term, open-label extension was conducted to study the safety profile and effectiveness of guanfacine XR for up to 2 years. All told, it is reasonable for this patient to continue on his Intuniv trial as it is an appropriate medication for this indication and the patients physician has documented that it has been effective.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old female enrollee has requested reimbursement for breast reconstruction surgery (mastopexy and mammaplasty augmentation with prosthetic implant). Findings:  The physician reviewer found that this patient presented with grade IV capsular contracture.  In this clinical setting, the Health Plan appropriately provided coverage for the capsulectomy and removal of breast implants.  Thus, anesthesia services and operating room charges associated with the capsulectomy and removal of breast implants should also be covered.  However, the submitted documentation fails to demonstrate the medical necessity of the breast reconstruction surgery (mastopexy and mammaplasty augmentation with prosthetic implant) performed on the date in question.  Based upon the medical records, the mastopexy and the mammaplasty augmentation with prosthetic implant were not medically indicated.  Mastopexy treats breast drooping and breast augmentation treats small breasts, and neither condition constitutes an abnormal structure of the body.  In this patients case, the breast reconstruction surgery performed (mastopexy and mammaplasty augmentation with prosthetic implant) does not meet the criteria for medically necessary reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential behavior health level of care. The enrollee entered a chemical dependency unit.  The enrollee has a history of multiple substance use, including heroin, alcohol, marijuana and methamphetamines, and reported abstaining from these substances for more than 30 days. The enrollee reported seizure activity prior to this admission. These were determined to be non-epileptic seizures. No seizure activity was observed during this admission. The enrollees vitals and withdrawal symptoms were monitored. Medications, group and individual therapy, and education were provided. The record revealed no acute withdrawal during this admission.  At discharge, records show the enrollee had achieved minimal progress in identifying triggers and cravings, depression, and family difficulties. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, treatment and recovery history, and acceptance and engagement. The enrollee has difficulties in relationships and with his ability to maintain responsibilities. He has not had success with previous treatment, but he does not currently engage in substance use. The enrollees composite LOCUS score is 21, which correlates with Level IV, medically monitored non-residential services.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for insulin pump (Medtronic 670G)Findings:  The physician reviewer found that at this time, the incremental benefit of automated closed loop control of insulin administration is unclear. The requested device, Medtronic MiniMed 670G system is a fairly new system. While the Medtronic 670G is U.S. Food and Drug Administration approved for management of type 1 diabetes, there is a lack of long term data available demonstrating health outcome benefits of such technology when compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device with or without CGMS.A study published the results of a pivotal safety study of the MiniMed 670G system in the Journal of the American Medical Association. The above studys purpose was limited to the evaluation of the safe use of the 670G auto mode function. This study was not designed to determine the effectiveness of the device compared to conventional methods such as manual daily insulin injections or non-automated insulin pump therapy. The authors concluded that longer term registry data and randomized studies are needed. Therefore, insulin pump (Medtronic 670G) is not likely to be more beneficial than the standard options for the management of this patients type I diabetes. Final Result: Two of the three reviewers determined that the requested device is 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: Physician reviewers 1,2 & 3  are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the percutaneous tibial nerve stimulation (PTNS) provided for treatment of the enrollees urinary incontinence. Findings:  The 3 physician reviewers found that this patient is symptomatic with urgency frequency and urgency incontinence. The etiology of her symptoms has not been established. She was placed on neuromodulation with PTNS. However, the records do not demonstrate that the patient has had a thorough evaluation with urodynamics as other etiologies including interstitial cystitis should be considered. PTNS is considered to be an appropriate salvage therapy for patients with intractable irritative lower urinary tract symptoms according to the American Urological Association (AUA) guidelines. All told, the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the service at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees super-morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One CHDR physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested oxycodone (30mg, one tablet every four hours) and Percocet (5/325, two tablets every eight hours) for treatment of his chronic pain.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The use of chronic opioid analgesic therapy in patients with nonmalignant, chronic pain is controversial.  Per the current medical literature, recent studies indicate that complications include adverse side effects and potential for addiction or diversion.  Many guidelines recommend careful consideration of continuation of chronic narcotics on a case-by-case basis.  Urine drug testing is recommended as part of routine surveillance for any patient on chronic narcotic medication.  Per the current medical evidence, continued use of narcotic pain medications is not medically indicated in this patients case.  Opiate tapering typically occurs in an outpatient clinical setting, and may involve the use of buprenorphine or adjuvant medications such as clonidine to assist with opioid withdrawal symptoms.  All told, the requested oxycodone (30mg, one tablet every four hours) and Percocet (5/325, two tablets every eight hours) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested lumbar spinal fusion (L5-S1) for treatment of her back pain. Findings:  The physician reviewer found that the submitted clinical evidence does not reveal signs or symptoms of radiculopathy in this patient (Tarulli and Raynor). Based on the submitted documentation, she has no spondylolysis or spondylolisthesis. Postoperative scar tissue is an expected finding in this patients case. It will be found in up to 25% of patients after fusion. It is an x-ray finding rather than a clinical disease. Postoperative scar tissue is not an indication for surgery unless radiculopathy, angulation, kyphosis or sagittal or coronal imbalance occurs, as noted by Cheh, et al. None of these conditions are present in this case. As such, the patient does not meet clinical indications for a lumbar spinal fusion.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested Vytorin for the treatment of her high cholesterol. Findings:  The physician reviewer found that in patients with hyperlipidemia, there are several medical options available for therapy, which are all considered within the standard of care in clinical medicine. With regard to this patient, she has been on a lipid-lowering agent for several years with an efficacious control of her hyperlipidemia. This patient failed treatment with Lipitor and has been maintained on a medication determined to be safe and effective for control of hyperlipidemia by the Food and Drug Administration (FDA). For these reasons, the patients continued treatment with Vytorin, as prescribed by her provider for effective control over her hyperlipidemia, is medically appropriate.