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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX device for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that The records demonstrate that this patient has GERD as based on pH recording. However, the patient has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in this patients setting must be approached with caution given his altered distal esophageal anatomy following the TIF surgery, and uncertain status of his upper gastrointestinal motility. Based on these findings, the requested LINX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested procedure 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 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.Physician reviewer number two 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.Physician reviewer number three 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 parents of a 17-year-old male enrollee have requested residential treatment service for treatment of his bipolar disorder.  Findings:  The physician reviewer found that according to the clinical record, the patient is violent and aggressive, and these behaviors are a manifestation of a severe psychiatric disorder, i.e., bipolar disorder. The patients aggressive behavior is a danger to others, especially those in his home and he has been unable to contract for safety. The patients condition has not stabilized despite several recent acute hospitalizations and he is not able to properly utilize outpatient treatment. There is a strong probability the patient will require further inpatient care if he remains at home.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a liver transplant candidacy evaluation for treatment of her liver disease.  Findings:  The physician reviewer found that in order to be referred for liver transplant candidacy evaluation, an individual must be deemed eligible for liver transplantation. Thus, acceptance as a potential liver transplant candidate is essential to establish the medical necessity of the requested liver transplant candidacy evaluation, as the evaluation serves the purpose of determining whether a potentially good candidate for liver transplant remains fit for such after medical and psychosocial evaluation. In this patients case, she has been diagnosed with liver disease with documented recent drinking and subsequent hospitalization.  The patient has had alcoholic liver disease-related presentations previous to her most recent admission and has, per the record, failed to successfully abstain from alcohol through various treatment programs. Thus, the patient does not meet the entry criteria for liver transplant candidacy evaluation given evidence of continued alcohol use and failure to actively participate in an alcohol treatment program despite previous similar decompensation. These factors are considered a major contraindication for liver transplantation and evaluation for such. For the reasons stated above, the requested referral for a liver transplant candidacy evaluation is not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested service is 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 internal medicine with sub-specialty certification in gastroenterology and transplant hepatology 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 58-year-old female enrollee has requested morphine and a referral to a spine specialist for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication and requested services.  The patients MRI does not indicate any pathology that will be amenable to surgery.  The current medical evidence does not support the use of morphine in this patients case.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy and injections to help reduce that pain.  High-dose opiates may cause adverse outcomes.  Baron and McDonald reported that high-dose opiates may contribute opioid-induced hyperalgesia.  All told, morphine and a referral to a spine specialist are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested Extracorporeal Shock Wave Therapy (ESWT) for the treatment of his left foot chronic plantar fasciitis and calcaneal spur. Findings:  Two physician reviewers found that the literature shows there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established and there is a lack of information regarding the durability of the treatment effect or any long-term adverse effects of ESWT. In addition, there have been some conflicting results among the randomized controlled studies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Wegovy.Findings: A study indicates that obesity is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. Additionally, the authors state, Weight loss of 510% results in improvements in cardiometabolic risk factors. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs.  According to another study, these medications increase glycemic control (with a low risk of hypoglycemia) and reduce body weight, blood pressure and cholesterol levels. Another review indicates multiple studies have demonstrated this medications ability to promote weight loss, facilitating weight loss, via reduced appetite and energy intake, and delayed gastric emptying, and likelihood of health risks associated with this medication has been noted to be quite low. In this case, the patient has been diagnosed with obesity and has a BMI of 38. Moreover, the patients condition is complicated by hypertension and GERD. Therefore, Wegovy is medically necessary for treatment of the patients medical condition.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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old male enrollee has requested for continued use of Velcade treatment regimen for treatment of his multiple myeloma. Findings:  Three physician reviewers found that Velcade (bortezomib) is an important drug for myeloma.  It is usually used up front in newly diagnosed patients and in those patients with relapsed disease.  Despite high response rates from bortezomib and other new agents such as thalidomide and lenalidomide, myeloma remains incurable. Thus, maintenance therapy has been considered to keep patients in remission. Interferon alpha, thalidomide and glucocorticoids have been studied in this setting, as noted by Engelhardt and colleagues.  Interferon has shown mixed results.  Thalidomide and prednisone has shown improved overall survival in at least one study, as noted by Berenson and colleagues.  This patient was enrolled in a clinical trial with a maintenance phase of Velcade. His disease has remained stable on this maintenance therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for budesonide (Entocort EC) for treatment of the enrollees ulcerative colitis. Findings:  The physician reviewer found that The documentation provided supports the medical necessity for the requested medication in this clinical setting. Corticosteroids are effective for the treatment of ulcerative colitis. The medical studies have shown that budesonide is unique in that it preferentially treats the gastrointestinal tract, avoiding the systemic side effects of steroids such as prednisone. Various forms of budesonide including Entocort EC are effective in small bowel disease, while other forms are targeted to the distal colon and rectum. Entocort primarily affects the ileum and ascending colon. These areas of the bowel including the ileocecal valve are inflamed in this case, and the medication has helped this patient. Final Result: The reviewers 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging (MRI). Findings:  Two physician reviewers found that the patient has a family history of breast cancer with her mother, who was diagnosed at age 48. A breast MRI was performed on 9/11/15 which was negative. Currently, the patient is requesting a breast magnetic resonance imaging (MRI), which she noted has been used in the past for her breast examinations. The patient requests authorization and coverage for breast MRI. The Health Plan denied the request noting that this test is investigational for evaluation of this patient. The medical evidence supports the requested services in this patients case. One study shows, Addition of MRI to mammography for screening BRCA1/2 mutation carriers age  50 years improves screening sensitivity by a magnitude similar to that observed in younger women. Limiting screening MRI in BRCA1/2 carriers age  50 years should be reconsidered. Moreover, another study performed by another study noted the following findings, Screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer. The data supports a key role for screening MRI in women who have an increased risk of breast cancer. Final Result: Two reviewers determined that the requested service 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: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested Botox therapy for the treatment of her TMJ-related tension headaches. Findings:  Two physician reviewers found that the enrollee has attempted a number of medications without sustained benefit and has recently achieved a significant reduction in symptoms with Botox therapy. She is now seeking authorization for further Botox therapy. Records demonstrate this patient has had success with Botox where other therapy has failed. It is likely she will again receive benefit from further Botox therapy. Furthermore, there is data to support Botox therapy for this patients headaches.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of a positron emission tomography (PET) scan of her breasts. The Health Plan denied the request indicating that the requested procedure is considered experimental for evaluation of possible breast cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested PET scan is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested PET scan is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for speech therapy for treatment of the enrollees autism spectrum disorder and pragmatic language disorder. Findings:  The physician reviewer found that that there is some evidence that social skills groups can improve social competence for some children and adolescents with autism. The patients testing results do not reflect his difficulties with social pragmatic language. In this case, continued speech therapy through the social skills group at Social Thinking was and is medically necessary for treatment of the patients autism spectrum disorder and pragmatic language disorder. 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:  Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental and 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: 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 Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, there was a new or changing development since prior studies. Tomosynthesis is of value in better distinguishing a mass in terms of its contours and margins than available alternative techniques. While tomosynthesis is generally not able to establish whether a mass is cystic or solid, a sonogram is generally performed as well to make that determination. Thus, in this clinical setting, the use of the digital 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 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:  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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested computer-assisted hip replacement surgery for treatment of her arthritis of the right hip. Findings:  Two physician reviewers found the requested services are not likely to be more efficacious than other treatment options.  The current medical evidence has not demonstrated the superior efficacy of the requested services, as outcomes have not been shown to be improved with this technology over standard techniques.  The use of computer navigation often results in increased time in the operating room.  Additionally, computer navigated cases have not been shown to have fewer complications compared to standard techniques.  All told, the requested computer-assisted hip replacement surgery is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested Ampyra 10mg for treatment of his multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medications.  This patient has been diagnosed with secondary progressive multiple sclerosis.  Per the medical records, he has progressive gait difficulty.  The current medical evidence supports the requested medication in this clinical setting.  Ampyra (dalfampridine) has been shown to improve walking speed and may improve lower extremity strength.  Improvement in function of demyelinated axons can improve gait and other function in this setting.  The documentation indicates that the patient previously responded to Ampyra.  All told, Ampyra 10mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested  for minimally invasive spinal surgery for treatment of his cervical stenosis. Findings:  The physician reviewer found that the objective of minimally invasive spinal surgery is to achieve the clinical outcomes attainable with conventional open surgery, while minimizing the risk of treatment-related injury. Multiple new technologies including microsurgery, laser technology, endoscopy, and video and image guidance systems have paved the way for these procedures. At the present time, until better scientific evidence is available, minimally invasive procedures such as laminectomy and foraminotomy should be regarded as research techniques. The patients underlying pathology is cervical disc bulge as well as disc-osteophyte complex. These problems can be satisfactorily addressed by anterior fusion but will not be addressed by a posterior procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the hand/wrist. While medical literatures note that MRI and ultrasonography are useful tools for evaluating the wrist, researchers report that for the management of De Quervains tenosynovitis, conservative management with splinting, icing, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy are recommended. In a case study of a patient with De Quervains tenosynovitis, researchers noted that conservative care involving NSAIDs and corticosteroid injections as well as occupational therapy to include splinting, activity modification, manual treatment, and therapeutic exercise were initiated. In this case, the patients history and physical examination are most consistent with De Quervains tenosynovitis. Given that conservative measures should first be trialed, the requested service is not medically indicated. Therefore, MRI of the hand/wrist is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 diagnostic radiology 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

An enrollee has requested reimbursement for neuropsychological testing. Neuropsychological testing is a form of testing that is used to determine neurocognitive implications of medical or neurological diseases. Testing is performed by a neuropsychologist and examines cortical dysfunction, specifically analyzing deficits in attention, memory, processing, language, motor function and intelligence. This patient underwent neuropsychological testing for depressive disorder, anxiety, and lapses in attention. There is a lack of evidence to support this testing with regards to anxiety and depression. Per the records, her complaints were due to an underlying psychiatric process where neuropsychological testing is not indicated. Therefore, neuropsychological testing was not medically necessary for the evaluation of this patient.