Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

A 61-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that at issue is whether a reasonable and prudent layperson in the patients circumstance would believe he or she was experiencing an urgent medical condition on the dates of service at issue. Urgently needed services are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area. The submitted evidence demonstrates that the patient presented on the first date of service at issue with low back pain. The patient did not experience an acute injury. In a letter, the patient indicates that he had an urgent need for services because of severe pain that caused him to be physically incapacitated with mobile impairment in his ability to walk. The MRI was recommended during the initial urgent care visit; no urgent neurological problem was noted. At that time, the patient had a negative straight leg raising exam and negative elevated leg test. No impairment in mobility was noted. On the second date of service at issue, the neurosurgeon indicated that upon gait exam, walking is normal. The patient has no difficulty with walking on his toes or heel. Tandem gait is normal. Romberg is negative. The patients back exam showed mildly limited range of motion. No tenderness to palpation. After the initial urgent care visit, a reasonable and prudent person would have sought authorization for follow-up care or returned to the plans service area to seek further evaluation and treatment. The record does not substantiate the patients contention that he was unable to return to the plans service area due to physical incapacity or impaired mobility. The submitted evidence does not demonstrate that a prudent person in this patients situation would reasonably believe that the disputed services, including an MRI, neurosurgical evaluation and multiple physical therapy sessions, were necessary to prevent serious deterioration of his health prior to returning to the plans service area. The patients symptoms on the dates of service at issue did not meet prudent layperson criteria for urgent care. The services the patient received could have been delayed until the patient returned to the plans service area and the evidence does not demonstrate that the patients condition precluded him from returning to the service area.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old male enrollee requested authorization and coverage of out-of-network acupuncturist referral and treatment for the treatment of a chronic aggravated trapezius muscle.  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: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested Real-Time Remote Heart Monitoring for an evaluation of his hypertension. Findings:  Two physician reviewers found that this patient has a history of hypertrophic cardiomyopathy and a new onset of symptoms of syncope and near syncope, thus longer term ambulatory ECG monitoring was indicated in this setting. To date, there are no large randomized data sets demonstrating which group of patients may benefit from Real-Time Remote Heart Monitoring. However, this particular patient has known severe structural heart disease and hypertrophic cardiomyopathy, which can carry significant risk for serious arrhythmias. The use of Real-Time Remote Cardiac Monitoring is recommended in patients with this type of structural heart disease and is most critical in the presence of syncopal-type symptoms in these patients. Thus, the services at issue were indicated and appropriate for this patient with significant underlying structural heart disease and significantly higher risk for severe cardiac arrhythmias.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavior analysis (ABA) therapy, eight hours per week of supervision, and three hours per week of parent training, for six months for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence-based interventions available. In this case, the patients family is requesting continued coverage of ABA therapy to address delays in adaptive, social, behavioral and communication skill sets. A treatment plan has been developed that is consistent with the patients essential health needs. ABA as a treatment is evidence-based and scientifically proven to be effective. The purpose of ABA in this case is to promote independence for the patient by addressing current deficits.  The correlation between treatment outcomes and treatment intensity is well-documented. In a recent article on the efficacy of ABA published by colleagues, the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this article, 726 children were studied and were shown to make increased progress towards learning objectives with increased intensity of treatment. Up to this point, the patient appears to have made progress in many areas, but he continues to demonstrate significant delays in social skills and adaptive skillsets as measured across multiple domains as well as severe behaviors (elopement and aggression).  He continues to require a high level of behavioral support.  Failure to master these skills not only puts the patient at an increased risk for injury, but also makes it increasingly difficult to be successful in more generalized environments. The current medical evidence supports the services at issue in this clinical setting.  All told, 40 hours per week of direct applied behavior analysis (ABA) therapy, eight hours per week of supervision, and three hours per week of parent training, for six months 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 sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for dosage escalation for Simponi injections every week.Simponi (golimumab) has proven effective for the treatment of Crohns disease and has been used in cases refractory to anti-tumor necrosis factor (anti-TNF) therapy. American Gastroenterological Association guidelines for the treatment of Crohns disease recommend an increase in the dose of anti-tumor necrosis factor medications, such as Simponi, when the drug level is low. Additionally, Lichtenstein and colleagues note, Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy, or advance to treatment for moderate to severe disease according to their clinical status. In this case, the patient has a low Simponi drug level. This patient has limited alternatives, and the dosage escalation of Simponi is supported by current medical literature. Therefore, the requested dosage escalation for Simponi injections every week is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast for evaluation of her medical condition.   Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this case, an area of architectural distortion was noted.   Breast tomosynthesis has been shown to be helpful in evaluating areas of asymmetry or distortion, which is often the only sign of an occult malignancy.  Thus, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  Final Result: Three 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:   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: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested Novolog insulin for medical treatment of the enrollees type 1 diabetes.  Findings:  The physician reviewer found that the most likely causes of episodic hypoglycemia in a child with suboptimally controlled diabetes on an insulin pump is variation in daily activity and diet, coupled with ever-changing insulin needs in growing children who have less beta cell reserve with longer duration of diabetes, rather than the specific type of insulin infused through the pump. All told, Novolog insulin is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old male enrollee has requested Velcade in combination with R-CHOP for treatment of his diffuse large B-cell lymphoma.  Findings: Three physician reviewers found that the patients lymphoma is of non-germinal center origin and that this type of lymphoma does not respond well to the standard R-CHOP regimen. The patient has requested Velcade in combination with R-CHOP. The peer reviewed medical literature suggests that the standard therapy for advanced diffuse large B-cell lymphoma involves chemotherapy with R-CHOP. The addition of Velcade to this combination has not been demonstrated to be superior to this combination in randomized controlled phase III clinical trials published in peer reviewed clinical literature. It is not FDA approved, compendium listed, or recommended by consensus panel guidelines for use in this clinical setting. Thus, its use would not be expected to facilitate an improved health outcome in this patient beyond the results anticipated with the R-CHOP regimen alone.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested for a bilateral breast magnetic resonance imaging (MRI) scan for evaluation of her medical condition. Findings:  The physician reviewer found that she has extremely dense breast tissue on mammography, which markedly limits the usefulness of this technique in her case. Recommendations for short term follow-up MRIs, based upon imaging findings which are probably benign, are very common in breast imaging and this is the case in this individual. The abnormal finding has only been visible on MRI; therefore, it stands to reason this technique will be the exam that needs to be repeated in order to assess stability. Since the area in question has only been visible on MRI, a biopsy in lieu of repeating the exam would be out of the question as a surgeon would need to identify the area in question to biopsy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin for 12 weeks for treatment of her hepatitis C virus. Three physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. For treatment-naive patients, therapy is recommended with Viekira Pak for 12 weeks (Class I, Level A recommendation). Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, treatment with Viekira Pak and weight-based ribavirin for 12 weeks is medically necessary in this patients case. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 left shoe orthotics. Studies indicate that limb length discrepancies more than 2.0 cm are frequently problematic and hip and knee pathology is present in an increased number of patients with limb length discrepancies over 0.5 cm. In addition, low back problems are reportedly common on same side of the body as the shorter limb. Studies concluded that the evidence suggests that gait deviations may occur with leg length discrepancies of more than 1.0 cm, with greater impact seen as the discrepancy increases. This patient presents with a history of severe trauma to the left lower extremity resulting in left foot and leg deformity. She is status post multiple reconstructive procedures, including left foot and ankle fusion with heel reconstruction. She has a documented leg length discrepancy of 1.9 cm and comorbid knee pain. She reported the left shoe orthotics help to correct her leg length discrepancy and manage her pain. The records document that she has been utilizing a left shoe orthotic on a long-term basis with functional benefit. Current evidence based medical literature supports the utility of shoe orthotics to reduce pain, improve function, and mitigate other musculoskeletal conditions in patients with leg length discrepancy. Therefore, the requested left shoe orthotics are medically necessary.Final Result: The reviewer determined that the requested device 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Anser IFX Prometheus blood test provided on the date of service in question and future testing. Findings:  The physician reviewers found that in this case, Anser IFX was ordered to determine infliximab level and whether antibodies to infliximab were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established. Studies have found that anti-infliximab antibodies can be transient and disappear over time, with many patients with antibodies maintaining their response. A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. For these reasons, the Anser IFX Prometheus blood test provided on the date of service in question and future testing was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was not and 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 32-year-old female enrollee has requested for Cyberknife stereotactic radiosurgery for treatment of her metastatic non-small cell lung cancer. Findings:  Two physician reviewers found that the patient has stage IV lung cancer that was treated aggressively with resection of brain metastatic disease followed by Cyberknife radiosurgery. She then received aggressive treatment for lung primary cancer and further treatment with Cyberknife. The patient presented with stage IV lung cancer and despite aggressive chemoradiation and further systemic treatment with Tarceva, she still has persistent systemic disease. Conventional palliative radiotherapy is appropriate in this setting. There is no data to suggest that Cyberknife treatment is likely to be superior to standard radiotherapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) of the heart. Findings:  Three physician reviewers found the current medical evidence does not support the services at issue in this clinical setting. The patient was asymptomatic with increased coronary risk and coronary calcification already being treated with high dose statin medication. In this circumstance, current guidelines do not consider screening coronary CT scanning appropriate. Specifically, therapy that already consists of high dose statin medication would not change regardless of test results. Therefore, CT of the heart was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 23-year-old female enrollee has requested  for laparoscopic placement of an adjustable gastric band (LAP-BAND) of her morbid obesity. Findings:  The physician reviewer found that if the patient has educated herself about the surgical options available to her, including duodenal switch, gastric bypass and LAP-BAND, and she is familiar with the long-term outcome of each, she should be offered to undergo a weight loss surgical procedure of her choosing.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 47-year-old woman with a chondral defect in the medial femoral condyle. A request has been made for an osteochondral autograft transfer system (OATS) procedure to fill in the defect. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the patients chondral defect.Given that the patient has an isolated lesion in the condyle that is not too large, she is an ideal candidate for the OATS procedure. The OATS procedure is used frequently to fill in small defects of the condylar weight-bearing surface. Furthermore, the patient does not have significant arthritis and the defect appears small enough that the OATS procedure is medically reasonable and appropriate. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.