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

The patient has requested authorization and coverage for exploratory laparoscopic surgery. Applying the guidelines from the American Society of Colon and Rectal Surgeons, this patients records do not support a current indication for the requested exploratory laparoscopic surgery (Paquette, et al.). The patient has been diagnosed with chronic constipation and pelvic dyssynergia. The documentation provided for review does not include a work-up concerning for chronic small bowel obstruction, which could support the proposed surgery (Knowles, et al.). Exploratory surgery with laparoscopy and lysis of adhesions is not recommended for the treatment for pelvic dyssynergia. All told, the requested exploratory laparoscopic surgery is 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 surgery with subspecialty certification in colon and rectal 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

A 49-year-old female enrollee has requested sclerotherapy for treatment of varicose veins.  Findings:  Three physician reviewers found that while there are published reports regarding the use of this method, it is not yet considered standard of care. Even the physicians own treatment options with the patient reflect the possible use of endovenous laser and surgical ligation and stripping. These are traditional standard of care alternatives. In this case, the use of ultrasound-guided sclerotherapy did not offer an advantage over traditional methods such as endovenous laser or radiofrequency. In May 2004 the dermatologic surgery journal listed guidelines of care for sclerotherapy of varicose veins, and it is not indicated as first-line treatment for truncal veins with incompetence.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed interferon regimens should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees delayed speech.  Findings:  The physician reviewer found that this patient has an identified delay in expressive and receptive speech of 40-50% per the DAYC subtest and the RITLS with a 30-40% delay in pragmatics. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested gene testing for evaluation of the enrollee, who has been diagnosed with attention deficit/hyperactivity disorder.  Findings: Three physician reviewers found that the submitted records do not demonstrate the superior effectiveness of the services at issue.  Specifically, the standard of care of attempting a second stimulant medication would have provided similar outcomes compared to gene testing results in this case.  Given that he had only attempted two medications prior to the testing, and only one was a stimulant, there is a lack of clinical justification based on substantial medical research to endorse genetic screening tests prior to attempting another medication for attention deficit/hyperactivity disorder.  Thus, gene testing was not likely to have been more efficacious than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in psychiatry with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

A 27-year-old female enrollee requested the LINX procedure (placement of esophageal sphincter augmentation device for medical treatment of her gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that this patients failure to respond to PPI therapy is a strong predictor that she will not experience a significant benefit from the requested anti-reflux surgery. For these reasons, the requested LINX procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene test for evaluation of the enrollee, who has a history of renal cell carcinoma.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records note that the patient has a history of clear cell renal carcinoma and is status post nephrectomy. It appears as if genetic tests were recommended in order to determine the chemotherapeutic regimen.  However, there is a lack of support for the services at issue in this clinical setting.  The specific genetic test requested involves testing for JAK2 mutation, which is not known to have a relationship to renal cancer.  Therefore, the requested genetic test was not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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

A male enrollee requested authorization and coverage of continued chiropractic care for back and neck pain.  The enrollees health plan denied the request indicating that continued chiropractic care is not medically necessary.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested a bone density scan (DEXA scan) for an evaluation of her bone density. Findings:  The physician reviewer found that the clinical indications for bone mineral density testing are well-documented in the literature. The published guidelines for bone mineral density testing recommend testing for all women over age 65. Additionally, this testing is recommended for postmenopausal women 60 to 65 years of age with one risk factor. These risk factors include fracture after age 45, hip fracture in a parent, tobacco abuse, bone mass index less than 22 and extended glucocorticosteroid use greater than three months. The guidelines also recommend bone mineral density testing in postmenopausal women of any age with non-traumatic fracture, incidental finding of osteopenia on x-ray, glucocorticoid use, hypogonadism or hyperparathyroidism. This patient does not meet any of these criteria.  All told, the requested bone density scan (DEXA scan) is not medically indicated for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old woman who presented with an explosive course of bronchoalveolar adenocarcinoma and respiratory failure. She had a dramatic response to treatment with Iressa. When she later reached a plateau on Iressa, she was switched to Tarceva.  The Health Plan indicates it will not authorize Tarceva because it is not considered medically necessary unless it follows failed treatment with a platinum-based chemotherapy.When this patient initially presented, she was too sick for chemotherapy.  She was treated with Iressa, an EGFR-targeted treatment, and had a remarkable response. Although Tarcevas current indication is for second line treatment, it is another EGFR-targeted treatment that is routinely being used for subsets of patients with a high likelihood of benefit.  This patients response to Iressa indicates the expected benefit of Tarceva is far greater than that of a platinum-based chemotherapy.  The Health Plans guidelines would require a failed trial of platinum-based chemotherapy before the patient could continue with Tarceva, the treatment most likely to produce a positive result. Uninterrupted treatment with Tarceva is a more prudent course of treatment for this patient.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS guidelines, the RTC services were not and are not medically necessary. The patient presents a composite score of 17, which correlates with intensive outpatient services. Moreover, the records do not establish that the patient has required the 24-hour supervision and medical monitoring provided at the RTC level of care. Given these findings, the RTC services were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for additional physical therapy. Current medical literature does not support the use of physical therapy modalities to correct pes-planus or intoeing resulting from internal rotation of the hip. Researchers explain that to understand variational pathologies of the lower limb, it is important to be familiar with the normal growth and development of childrens lower extremities, noting that neonates are born with about 40 degrees of femoral anteversion or forward rotation of the femoral neck, and that this increased internal rotation of the hip decreases over time. The mainstay of management is observation and researchers state that parental education and reassurance is an important part of the treatment and must be re-emphasized. The authors further note that shoe inserts, orthoses and physical therapy are not to be encouraged as they provide no benefit, and that in the majority of cases, the natural history is one of spontaneous resolution of the deformity. In this case, the patient does not have a skeletal deformity, is independent with mobility, and does not have neurological deficit, and does not report pain. The records document mild limitations with recreational and competitive sports. The patient has functional range of motion in all joints of lower extremities. His gait pattern consists of benign intoning that does not interfere with function. In this clinical setting, additional physical therapy is not medically indicated. Therefore, additional physical therapy is not medically necessary for the 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 with sub-specialty certification in pediatric rehabilitation 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: Upheld

A 20-year-old female enrollee has requested residential treatment services for treatment of her eating disorder.  Findings:  The physician reviewer found that a retrospective review of the entire medical record supports a conclusion that the patient was able to move to a PHP level of care as of the date in question. An optimal program would offer intensive individual therapy for victims of sexual abuse, family therapy and monitoring of her eating disorder. The last certified date is consistent with the patients readiness to move to a lesser level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings in the interpretation of mammograms particularly in cases of heterogeneously dense tissue such as in this case. The technique allows radiologists to separate dense glandular elements from underlying architectural distortion/mass in many cases thereby reducing callbacks and increasing the detection of small cancers. 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 number one, two, and three 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral lumbar radiofrequency ablation for treatment of his medical condition. Findings: Two physician reviewers found that lumbar medial branch radiofrequency ablation or neurolysis is a well-documented procedure which helps with chronic low back pain due to lumbar facet pain. The records indicate that this patient underwent medial branches in the past with success.  Son and colleagues noted that repeated radiofrequency ablation for lumbar facet syndrome provided successful pain relief for about 10 months in more than 85% of carefully selected patients. The procedure is successful in treating lumbar spine pain in repeated fashion.  However, since the patients prior intervention was a number of years ago, a repeat radiofrequency ablation is not indicated until a confirmation block is performed with success at diminishing the patients pain.  Therefore, the superior effectiveness of the requested services has not been demonstrated.  Final Result: Two reviewers determined that the requested services are 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested neck surgery for the treatment of his cervical degenerative disc disease. Findings:  Three physician reviewers found that the available medical literature shows promise in total disc replacement at one level however the devices used in these procedures are still undergoing studies to determine their long-term overall safety and efficacy. Further, there is a paucity of evidence supporting replacements at more than one level. Murrey and colleagues reported that there are no large, scientific studies showing the long-term safety and effectiveness of the devices, only short-term (less than two-year follow-up) studies. Brown and Heller noted that the indications for ACDF are similar to those for disc replacement and limited to patients with documented cervical radiculopathy or myelopathy. This patient presents with chronic neck pain without evidence of radicular or myelopathic findings on examination. Thus, cervical disc replacement at two-levels and ACDF are not medically indicated for this patient without documented radiculopathy or myelopathy. Even if this patient were a disc replacement candidate, current guidelines only recommend one-level replacement. All told, total disc replacement remains experimental and investigational as the Food and Drug Administration (FDA) has required each of the devices to undergo post-marketing studies to fully establish the long-term safety and efficacy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male has requested speech therapy services at a frequency of three sessions per week for 30 minutes per session for treatment of his autism.  Findings:  The physician reviewer found that the key to this members case is that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorder.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health.  Thus specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. I find the requested services to be medically necessary based on overall evaluation of the literature and this patients medical records.