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

A 47-year-old female enrollee has requested magnetic resonance imaging (MRI) of the cervical spine for evaluation of her medical condition status post motor vehicle accident.  Findings:  The physician reviewer found that this patient has chronic pain and plain films show abnormal motion at C4-5 likely causing neural impingement. The records indicate that conservative therapy has been tried but has not provided substantial relief of the patients symptoms. Based on the American College of Radiology (ACR) imaging criteria, MRI is the next reasonable test for evaluating the patients cervical spine and is important to determine if intervention should be considered. For these reasons, the requested MRI of the cervical spine is medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines do not support the DecisionDx testing for use outside of the clinical trial setting. Moreover, there is a lack of peer-reviewed medical literature demonstrating that the results of the DecisionDx-Melanoma Assay would change the recommended therapy or long-term outcomes. Consequently, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was 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 dermatology 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 female enrollee requested Harvoni 90-400 mg for 24 weeks for medical treatment of her chronic hepatitis C virus genotype 1b.  Findings:  Three physician reviewers found that the patient has hepatitis C virus cirrhosis which places her in the category of patients who need hepatitis C virus urgently, as classified by the national guidelines on treating hepatitis C virus published by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The patient has relapsed after a prior sofosbuvir, peg interferon and ribavirin regimen. In this clinical scenario, the guidelines support retreating patients who failed a prior sofosbuvir-containing regimen with Harvoni with or without ribavirin for 24 weeks, especially in the presence of cirrhosis. This patient satisfies these criteria and should be treated with the requested Harvoni 90-400 mg, which is medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Orthovisc injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The researchers reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patients records document consistent relief with hyaluronic acid injections. Thus, repeat hyaluronic acid injections were appropriate. Accordingly, the Orthovisc injections provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement, and authorization and coverage for 16 hours of direct applied behavioral analysis (ABA) services per week. The submitted documentation does not support the request for 16 hours of direct ABA therapy per week. While the National Autism Centers national standards project highlights that ABA is an effective treatment for individuals with autism, this project is not a study that recommends the exact dosage of ABA. BACB autism guidelines divide treatment intensity into comprehensive and focused, highlighting that time away from treatment may result in a client falling further behind their peers. In this case, while the patient is having his hours decreased, the patient will not be spending time away from services. The submitted documentation reflects that the patient has made progress on skill acquisition goals in the areas of language and adaptive behavior, and accomplished significant decreases in non-responsiveness and skin picking. Furthermore, while the provider has indicated that the patient has a history of engaging in aggressive behavior, this is not a behavior that the provider is currently assessing or treating, as there was no mention of this behavior in their most recent progress report. Under these circumstances, the request for 16 hours of direct ABA therapy per week is not supported by the submitted documentation. Accordingly, 16 hours of direct applied behavioral analysis (ABA) services per week is not medically necessary for treatment of the enrollees medical condition. 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 a board-certified behavioral analyst and psychologist, 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 parent of a six-year-old male enrollee has requested speech therapy for treatment of speech and language deficits.  Findings:  The physician reviewer found that childhood apraxia of speech is a controversial issue and the peer reviewed literature does not wholly support apraxia as an individual diagnosis with specific clinical criteria. Language delays that are unrelated to a medical diagnosis are generally considered developmental, and are best addressed by the school system. While speech therapy may be appropriate to treat the patients speech deficits, the therapy is not medically indicated in this instance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Januvia 100 mg. Januvia and Tradjenta are members of the same class and are considered equally effective barring any renal or hepatic function impairment. Thus, these two medications are substituted for one another. This patients records do not include documentation from the patients provider that one medication has been more effective than the other. In addition, there is no evidence that the patients diet and exercise and weight were the same while being treated with both medications. Thus, there is a lack of documentation to support the use of Januvia in lieu of Tradjenta. Accordingly, the requested Januvia 100 mg is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication 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 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: Medical Necessity
Decision: Upheld

The patient is a 10-month-old male with plagiocephaly. His parents are seeking authorization for a cranial orthosis/band. The patient has been evaluated by appropriate specialists and neck physical therapy and a cranial band have been recommended. The Health Plan has denied authorization for the cranial band.The treatment of plagiocephaly with helmet molding is controversial. Studies regarding the efficacy of helmet therapy are limited with varying results. Helmet therapy is generally utilized for patients in early infancy with severe problems such as facial changes. This patient is not in early infancy and does not have severe problems. There is insufficient scientific and clinical evidence to support helmet therapy in this patient. Therefore, I have determined the requested equipment is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee requested authorization and coverage of pegylated interferon (PEG-Intron) for the treatment of hepatitis C.  The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee has requested X-Stop implantation for the treatment of his lumbar spinal stenosis. Findings:  Three physician reviewers found that this 68-year-old male patient has a history of spinal stenosis with failed conservative treatment. Evaluation of the patients condition demonstrates canal stenosis at L4-5 with degenerative spondylothesis at that level. Although the patient meets many criteria for the X-Stop procedure, his MRI findings demonstrate he would be better served by standard neurosurgical decompression with or without fusion. Furthermore, while there is some data to support the risk and benefits of the X-Stop it has not been established as a more effective procedure than decompression with or without fusion.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nerve block injection of knee. Findings:  The physician reviewer found that the patient has chronic right knee pain with previous total joint replacement complicated by infection. The patient has been treated with physical therapy, medication management, and steroid injections with limited benefit. The patients provider has recommended a nerve block injection in the right knee. However, there is a paucity of evidence supporting genicular nerve blocks and subsequent radiofrequency ablation as equivalent or superior to standard of care treatment options. A review by Billesberger and colleagues evaluated genicular nerve radiofrequency ablation and reported that, Despite this therapy being available for decades, there is limited evidence in the literature describing its benefit. Similarly, Cheppalli and colleagues commented that, In our review, we noted that there is a lack of high-quality studies on this topic. The authors concluded that, The available studies are not well structured and do not provide the best evidence. Based on the records for review and medical literature, the requested nerve block injection of knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for psychiatric residential treatment center (RTC) services. The submitted documentation supports that psychiatric RTC services for the period in dispute were medically necessary. The submitted records reflect that the patient was not performing activities of daily living and she continued to have suicidal ideation. She did not have any delusions or hallucinations, but showed an appropriate affect in a depressed mood. The patient was cooperative with care, was actively involved in her treatment, and followed through with assignments. The patient had a composite score of 21-26 for the period of treatment in dispute. This correlates with treatment in a residential treatment facility. Therefore, psychiatric RTC services provided during the period in dispute were medically necessary for treatment of the patient. Regarding the recommended prospective ninety (90) days of continuous psychiatric residential treatment center services, the patient has a composite score of 19, which correlates with intensive outpatient treatment. However, given the significant score of 4 on the risk of harm, the American Association of Community Psychiatrists Level of Care Utilization System strongly recommends a medically managed or monitored residential setting. Thus, 90 days of continuous psychiatric RTC services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services in issue were medically necessary for treatment of the patients medical condition. The reviewer also determined that the requested services going forward 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 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: Experimental/Investigational
Decision: Upheld

The parent of a nine-year-old female enrollee requested the Zio Patch heart monitor for medical evaluation of the enrollees chest pain. Findings:  Three physician reviewers found that given this patients presentation, further testing is likely to be of low yield since the signs and symptoms are not consistent with a cardiac origin for the chest pain. Given this patients low risk of cardiac arrhythmia, lack of a positive family history, and lack of evaluation by established methods, the request for use of the Zio Patch heart monitor is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested coverage for an out-of-Plan referral for neurovascular assessment for treatment of her lightheadedness and near syncope.  Findings:  The physician reviewer found that the differential diagnosis for such symptoms is broad and includes hyperventilation, orthostasis, arrhythmia, metabolic disturbances, and anxiety. Della-Morte and Rundek reported that, vertigo, nausea, and vomiting, along with nystagmus, represent symptoms of stroke in posterior fossa due to arterial occlusion or rupture of the vertebrobasilar system. In addition, the literature shows a variety of presentations of carotid-jugular fistula, typically including pulsatile mass, or potentially with congestive heart failure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that according to the referenced literature, articulation disorder treatment involves demonstrating how to produce a sound correctly, practicing sounds in different words, and learning recognize which sounds are correct and incorrect. The clinical documentation submitted for review failed to demonstrate significant speech abnormalities. Given the lack of documentation supporting a speech/language disorder and the need for ongoing therapy, the services at issue were not medically necessary. As such, the requested speech therapy is not medically necessary for treatment of the patients medical condition. 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 pediatric 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: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested for Erbitux chemotherapy in combination with Taxotere for treatment of his condition.   Findings:  Two physician reviewers found that Erbitux is one of a newer group of drugs that appear to work by inhibition of epithelial growth factors. It has been approved in certain situations in metastatic colon cancer, as well as cancer of the head and neck. In the latter type of cancer, Erbitux did appear to increase survival when combined with radiation therapy in patients with locally or regionally advanced disease. One study has been published using single agent Erbitux in patients in whom prior therapy with cisplatinum had failed. This demonstrated a 13% response rate with a median duration of response of 5.8 months. Being a single arm study, there was no way to determine its efficacy relative to other possible therapies. There is no good data to indicate that Erbitux adds efficacy to the use of Taxotere in patients such as this patient. This is investigational and of no proven benefit.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 36-year-old female who underwent surgery for chondromalacia in November 2005. Following surgery she was prescribed a continuous passive motion (CPM) machine. The patient has requested reimbursement for the CPM device. The Health Plan has denied this request based upon their determination that the device at issue was not medically necessary.The use of a CPM device following the type of surgery that was performed in this case is a well documented treatment option for postoperative management. CPM therapy is beneficial to the healing and rehabilitation processes. Many surgeons prescribe the CPM machine for their patients postoperatively and such prescriptions are consistent with the surgical communitys standard of care. The use of the CPM device was medically appropriate and indicated in this clinical setting. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Dexcom G6 continuous glucose monitor (CGM) system (sensor, receiver, transmitter). Olczuk and Priefer note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. The authors note that while finger-prick devices have commonly been used to monitor blood glucose, CGM systems have recently been refined and improved for home use. Zheng and colleagues note that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. In this case, the patients glycemic control has been improving since they began using the Dexcom CGM. Given that current medical literature supports the use and accuracy of CGM systems, such as the Dexcom G6, for home monitoring of glucose levels, the requested equipment is medically indicated. Therefore, a Dexcom G6 CGM system (sensor, receiver, transmitter) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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.