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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that in this patients case, the services at issue were likely to have been more effective than other methods of evaluation.  Per the medical evidence, breast tomosynthesis is of particular benefit for evaluating patients with extremely dense or heterogeneously dense tissue.  The utility of the new technique relates to the ability to separate dense glandular tissue from architectural distortion.  The result is a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of the technique was likely of more benefit to the patient than had the mammogram been done with two-dimensional imaging alone. 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: Overturned

A 25-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder. Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Transcranial magnetic stimulation has been endorsed by the American Psychiatric Association for the treatment of individuals with depression.  In this particular case, the patient was reportedly enduring an acute major depressive episode that caused significant morbidity and functional impairment.  He had pursued other standard therapies used to combat depression.  Considering the patients medical records and expanding peer-reviewed literature base, transcranial magnetic stimulation was an appropriate treatment.  All told, transcranial magnetic stimulation provided from the time frame specified was medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for out-of-network surgical services on the basis that the services were emergent in nature. Fingertip crush injuries with laceration and distal phalanx fracture are common injuries and fortunately, the risk of infection is low. Studies have not found benefit to prophylactic antibiotics and have confirmed that operating room washout of the wound is unnecessary. The surgery was performed over two weeks after the accident and did not constitute emergent treatment. The surgical services were not necessary for treatment of an emergency medical condition as defined above.Final Result: The reviewer determined that the patient did not receive emergency medical services. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and hand 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: A female enrollee has requested reimbursement for office medical services (89353). The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who presented for infertility services. This is a situation where the patient was unable to get pregnant because she was not in a current sexual relationship and was around the age limit of natural fertility. She underwent intrauterine inseminations and in vitro fertilization (IVF) in an attempt to conceive. The contention that these were not infertility treatments but instead were preconception/prenatal care is not supported by the records or the billing, and the services were in fact provided by an infertility clinic. Furthermore, because of the patient's age, the infertility treatments she received had a very low chance of success. Her intrauterine inseminations failed, and the IVF cycle produced poor results. While it is unknown what happened with the remaining single embryo transfer, an unsuccessful outcome in this setting would not be unexpected as noted in an Up To Date review on IVF:  `The major determinant of the success of IVF is the age of the woman. Although IVF may largely overcome infertility in younger women, it does not reverse the age-dependent decline in fertility in older women, particularly those over 40 years...In IVF, the diminished success is due both to decreased ovarian responsiveness to gonadotropin stimulation, resulting in a decreased number of oocytes available for IVF, and a decreased implantation rate per embryo transferred due to poor egg quality. In addition, the risk of spontaneous abortion is significantly higher in older women.Findings:  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 parent of an enrollee has requested authorization and coverage for occupational therapy services. Findings:  The physician reviewer found that a set of guidelines on the management of children with autism spectrum disorder published by the American Academy of Pediatrics, Hyman and colleagues note that occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. According to Bilaver and colleagues, almost two-thirds of preschool-aged children with ASD are reported to receive occupational therapy services. Many parents of children with autism spectrum disorder have described significant problems due to the coronavirus pandemic. Children with autism spectrum disorder frequently have difficulty attending to telehealth therapy. Goldberg notes that many children with autism spectrum disorder have lost previously acquired skills during the coronavirus pandemic. Manning and colleagues describe stress around therapeutic service disruption in families of children with autism spectrum disorder due to the coronavirus pandemic. In this case, the patient has autism spectrum disorder, and still requires verbal prompts to complete activities of daily living. The patient has had documented regression during the pandemic, during which time he has not been receiving therapy services in person. He has had an increase in self-stimulatory hand stereotypies, which are interfering with his ability to have appropriate adaptive function at home. Therefore, occupational therapy services are medically necessary to correct or ameliorate physical or behavioral conditions.Final Result: The reviewer 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: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee requested authorization and coverage of Z-plasty and blepharoplasty procedures. The Health Plan denied the request indicating that the requested procedures are not medically necessary for facial reconstruction post Mohs surgery and radiation treatment.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that a Z-plasty is medically necessary but a blepharoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested Sovaldi for treatment of her hepatitis C virus genotype 2b.  Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) indicates that an interferon regimen is the preferred treatment for hepatitis C virus genotype 1. However, the standard of care for hepatitis C virus genotype 2 includes combination therapy with Sovaldi and ribavirin. In addition, three high quality trials support the combination of a polymerase inhibitor with ribavirin for treatment of hepatitis C virus genotype 2. Consistent with these findings, the requested medication regimen with Sovaldi and ribavirin is 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 for the FoundationOne genomic analysis. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered within the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines advises broader molecular profiling with the goal of identifying rare driver mutations for which effective medications may be available, or to appropriately counsel patients regarding the availability of clinical trials. Thus, the FoundationOne genomic analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the FoundationOne genomic analysis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Overturned

Nature of Statutory Criteria/Case Summary: A 60-year-old male enrollee has requested reimbursement for the percutaneous kyphoplasty for treatment of his severe back pain. Findings:  Two physician reviewers found that traditional open surgery has numerous complications, and radiation therapy may take weeks to become effective. To avoid the trauma and complication of open surgery, percutaneous kyphoplasty (PKP) is a minimally invasive procedure that has played a great role in the treatment of spinal metastases over the past several years. Researchers found that as a minimally invasive procedure, PKP may not only rapidly relieve the pain and disability experienced by patients, but it may also restore the kyphotic angle observed at the one-year follow-up. Notably, PKP may safely improve the quality of life of patients. Researchers reported that balloon kyphoplasty is a minimally invasive procedure that provides immediate and long-term pain relief and improvement in functional ability in selected patients with metastatic vertebral compression fractures. The procedure appears to have good long-term safety. Similarly, other research provided support for the procedure stating that kyphoplasty is a safe and effective procedure for treating painful vertebral body fractures caused by metastasis and multiple myeloma. It can restore vertebral body height and correct the kyphosis angle. Thus, the literature does support the use of kyphoplasty to provide pain relief and improve the functional capacity of patients with painful or unstable metastatic vertebral compression fractures. 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 diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services including 90 minutes of physical therapy and occupational therapy per day. Meningioma is the most frequent primary tumor of the central nervous system with known progression or recurrence in a subset of these tumors following resection (Gupta, et al.). Treatment options for recurrent meningiomas include surgery and radiation. Systemic therapies have been found to have limited efficacy in this clinical setting (Apra, et al.). This patients records document persistent deficits including mild cognitive deficits and left hemiparesis following surgical debulking of a recurrent meningioma. The patients cognitive deficits have negatively affected their insight and processing abilities. The patients left hemiparesis and obesity have limited their functional progress with respect to self-care and basic mobility. Despite one month of rehabilitation services, the patient continued to require maximum to total assistance for their self-care and basic mobility needs. There is a lack of documentation of significant neurological recovery since the patient started rehabilitation services. Thus, reintroduction to rehabilitation services from the custodial care setting to the SNF treatment level of care is not anticipated to result in improved function or outcomes for this patient. In addition, the patient does not have any reported skilled nursing needs. For these reasons, the requested SNF services including 90 minutes of physical therapy and occupational therapy per day are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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

The patient is a 40-year-old female who has undergone rhinoplasty and is requesting reimbursement for the stated functional septoplasty portion of the surgery. The patient states that she has been told in the past that her septum was deviated and that rhinoplasty would be necessary to correct this. She further indicates that her nose was obviously not straight and blocking her airway passage. There is no documentation of problems with nasal airway restriction. The plastic surgeons notes indicate that the patients nose had a prominent tip and wide nostrils. Pre-operative photos show that the patient had a bulbous nasal tip that was fuller on one side than the other. There was a hanging columella that was deviated to one side as well, resulting in asymmetry of the nostrils. The patient underwent open rhinoplasty in November 2004. The dictated operative note demonstrates that a reduction of the dorsal septum was performed. There is no other mention of septal work having been performed during the procedure.At issue is whether any portion of the surgery at issue as medically necessary for treatment of the patients condition.There is no evidence the surgery at issue was performed for functional purposes. The submitted records do not include any discussion of septal deviation or airway restriction. Furthermore, there is no mention of a septoplasty having been performed other than reduction of the dorsal aspect of the septum. This would lower the height of the septum and, in turn, the dorsum of the patients nose, but would not affect a deviation of the septum. As such, I have determined the surgery at issue was cosmetic in nature and therefore, 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: A female enrollee has requested reimbursement for the gastrointestinal (GI) tract capsule endoscopy. This patient presented with symptoms and visual colonoscopy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and is superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has proven superior to all current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. The frequency of small intestinal Crohns disease activity found by capsule endoscopy in a consecutive series was approximately double that detected by computed tomography (CT) enterolysis, leading to changes in the management of a significant number of patients. For these reasons, the GI tract capsule endoscopy was likely to provide useful diagnostic information in this case, and was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.One reviewer found that the GI tract capsule endoscopy was not likely to provide useful diagnostic information in this case, and was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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 50-year-old male with a recurrent grade III abdominal liposarcoma, status post two resections and alternative immunotherapy. He now has progressive disease. The patient is largely asymptomatic and has had no chemotherapy or radiotherapy. He is in good clinical condition. A request has been made for coverage for insulin potentiation therapy. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients medical condition. There are shreds of scientific data that provide a rationale for insulin potentiation therapy with chemotherapy in an effort to augment chemotherapy response. Cancer patient trials, however, are limited to anecdotal reports and none involve soft tissue sarcomas. As such, there is no basis to recommend insulin potentiation therapy prior to standard treatment outside of a clinical trial. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for the medication Trulicity. Trulicity is a member of the Glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. While all of these medications may be efficacious with regard to improvement of glycemic control, Trulicity is unique in that it has demonstrated potential to reduce the likelihood of cardiovascular events in patients with type 2 diabetes who do not have a known history of cardiovascular disease. In this case, while the patient does not have known cardiovascular disease, he is on statin therapy for dyslipidemia, which is a cardiovascular risk factor. Under these circumstances, Trulicity is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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 subspecialty certification in endocrinology, diabetes and metabolism, 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.