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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation with a neuropsychiatrist with a board certification in psychiatry and neurology. There is evidence that a neuropsychiatric evaluation is warranted in traumatic brain injury (TBI) cases. Campbell noted that, Neuropsychiatrists evaluate patients with neurological disorders and general medical conditions who are experiencing psychiatric symptoms. Knowledge of functional neuroanatomy of the central nervous system is essential to offer accurate diagnoses and treatments. This patients records document that she has undergone treatment with a neurologist for the diagnosis of mild TBI with cognitive and speech issues possibly exacerbated by untreated depression and anxiety. There is further report that the patient underwent a prior neuropsychiatric evaluation. The medical literature recommends a neuropsychiatric evaluation in patients with TBI but does not specify that the specialist performing such an evaluation needs to hold board certifications in both neurology and psychiatry. A qualified neurologist with experience in treating patients with TBI can address the neurologic aspects of TBI, and a separate provider with background in either psychology or psychiatry can focus on the patients mood disorders that arise out of TBI. For these reasons, the requested consultation with a neuropsychiatrist with a board certification in psychiatry and neurology is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 physical medicine and rehabilitation with subspecialty certification in pain management 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: A enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). Findings:  The physician reviewer found that criteria does not support the clinical utility of breast MRI in this clinical setting. The recommendation that for patients with complaints of pain without a focal mass and lactating, that mammography is the first-line examination and then ultrasound as clinically appropriate. The guideline does not consider MRI in these clinical scenarios to be the appropriate examination of choice. Thus, the requested bilateral breast MRI is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are 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: Overturned

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism spectrum disorder and speech-language disorder. Findings:  The physician reviewer found that the etiology of autism has not been clearly delineated, but the consensus is that it is a congenital disorder. The highlight of dysfunction in autism is a communication defect. Consistent speech therapy on a one-to-one basis is the only known method of improving communications in an autistic child.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested Olysio (simeprevir) and Sovaldi (sofosbuvir) for treatment of his Hepatitis C status post liver transplant. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) recently approved Sovaldi, a nucleotide analog polymerase inhibitor and Olysio, an oral protease inhibitor, for treatment of patients with hepatitis C virus infection. There is ample data supporting the efficacy of Sovaldi and Olysio given their improved efficacy and tolerability, oral route of administration, and shortened treatment duration requirements. Prior to the introduction of Sovaldi, treatment options for interferon ineligible hepatitis C patients have been limited. In patients with hepatitis C virus genotype 1 infection who cannot take interferon, use of Sovaldi plus ribavirin for 24 weeks may be considered as an alternative (Osinusi, et al). However, this patients records document a history of neutropenia, which suggests he is not a good candidate for FDA approved interferon-free regimen of Sovaldi plus ribavirin. Overall, once daily treatment with Sovaldi and Olysio, with or without ribavirin has been shown to be highly effective in both treatment naive patients and prior  responders infected with hepatitis C virus, genotype 1, including patients with cirrhosis. For these reasons, the requested medications are supported as medically necessary for treatment of this patients hepatitis C virus infection and advanced liver disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BRCA1 and BRCA2 genetic testing for evaluation of her medical condition.  Three physician reviewers found that the requested testing is not likely to be more effective for this patient than other available options. The National Comprehensive Cancer Network (NCCN) guidelines state that testing criteria includes an Individual from a family with a known deleterious BRCA1/BRCA2 mutation. In this case, there is no documented family history of a known deleterious BRCA1/BRCA2 mutation or that her family members breast cancer was triple negative. There is also not a personal history of breast cancer. Thus, BRCA1 and BRCA2 genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Three reviewers determined that the requested testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified in medical oncology 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 64-year-old male has requested electrical therapy, via implantation of neuroelectrodes (CPT 64575)/peripheral lead implantable nerve stimulator for treatment of his chronic back pain.  Findings:  Two physician reviewers found that the patient is status post an L2-3 interbody fusion. The patient also has undergone conservative treatment with epidural steroid injections (ESIs), physical therapy and chiropractic manipulation. The patient continues to have low back pain and a post operative MRI demonstrated facet arthropathy, disc dessication and an annular tear L1-2. The patient is currently receiving treatment with the following medications: Ultram, trazodone and gabapentin. Subsequent to a pain medicine consultation the patients provider recommended a trial of peripheral field stimulation, as the patients pain distribution is likely not amenable to spinal cord stimulation. There is considerable evidence that spinal cord stimulation is an effective treatment for low back and leg pain in properly selected patients. However, there is limited data available in the peer reviewed medical literature examining the effectiveness of peripheral nerve stimulation in patients having axial low back pain without a radicular component, as is the case with this patient. There is not yet sufficient evidence to conclude that peripheral nerve stimulation is likely to be more beneficial for treatment of the patients chronic low back pain than other standard therapies, such as spinal cord stimulation and other less invasive therapies.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. At issue in this case is whether the requested Nutropin AQ Nuspin 20 mg is medically necessary for treatment of the enrollees medical condition.This patient has been growing between the 50th and 25th percentile for height without significant linear deceleration that crosses percentiles. His height was 139.8cm and 134.1cm in the previous year. This gives him an actual growth velocity of 5.7cm in one year, which is great and does not suggest poor growth. The last bone age study was done at 10 years of age, which was read as bone age of 10 to 11 years old, giving him an estimated adult height of 67.5 inches. His mid parental target height is 69.75 inches. He had a growth hormone (GH) stimulation test with clonidine and another one with glucagon, with both values <10ng/m (6.3 with glucagon and 7.2 with clonidine) He had a normal magnetic resonance imaging (MRI) pituitary and later started on growth hormones (GH).The failed GH stimulation tests noted in the records, in the absence of poor growth, do not suggest GH deficiency as there can be false positive tests for the diagnosis of GH, especially in pre-pubertal children. There is not one single test that makes the diagnosis of GH but rather a constellation of clinical and biochemical features, which this patient does not have based on the medical records.There is no documentation of the pubertal state of this child. Pre-pubertal children or children with late puberty can experience small linear decelerations that are temporary and do not require treatment with GH. The estimated predicted adult height of this patient based on the bone age is within the normal range for his mid-parental height. It is also within the normal range for an adult male. Therefore, the requested growth hormone Nutropin AQ Nuspin 20mg is not medically necessary. 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 pediatrics, with subspecialty in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Rituxan 375 mg/m2 once per week for four weeks for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  Two physician reviewers found that this is patient with chronic inflammatory demyelinating polyneuropathy (CIDP) with progressive functional decline on standard therapies including intravenous immunoglobulin (IVIG) and prednisone. Despite standard medical management, the patient has progressed to a walker, had developed additional knee weakness, and has had several near falls. The patient is also at risk of significant side effects from the use of his high dose prednisone and IVIG. While Rituxan is not recommended for all patients with CIDP, it has been shown to be beneficial in select groups of patients. Undertreated CIDP can lead to rapidly worsening functional status and potentially severe injury due to fall. In addition, the long-term use of prednisone can lead to cataracts, osteopenia, hypertension and other untoward side effects. To this end, it is reasonable to treat this patient with Rituxan given the provided documentation. For these reasons, the requested Rituxan 375 mg/m2 once per week for four weeks is supported as 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 medication is 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 neurology with sub-specialty certification in pain medicine 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dextroamphetamine tablet for treatment of the enrollees demyelinating disease of central nervous system. Findings:  The physician reviewer found that Adderall is not U.S. Food and Drug Administration (FDA) approved for fatigue management related to multiple sclerosis. In the medical literature, it is noted that multiple therapeutic treatments are available for multiple sclerosis related fatigue. However, the authors noted that Adderall is not supported in the peer-reviewed medical literature for use in this clinical setting. Further, it is reported that Adderall has not shown benefit in treatment of patients with fatigue related to multiple sclerosis. 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 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: Upheld

A 52-year-old male enrollee has requested continued skilled nursing facility services for the treatment of his paraplegia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Spinal cord injuries can result in functional impairments requiring complex, individualized rehabilitative measures.  In this case, the patient developed new onset paraplegia following trauma related to a suicide attempt during the specified date.  After he was surgically and medically stabilized, he was appropriately transferred to acute inpatient rehabilitation for further care.  Acute inpatient rehabilitation is generally indicated as the initial setting of rehabilitation for this patients condition.  He underwent extensive rehabilitation, but made only minor progress.  The patient still required maximum assistance for most of his activities of daily living and mobility, including transfers and wheelchair propulsion, at the time he underwent his initial therapy evaluations at the skilled nursing facility at a specified date.  He has only made modest additional progress since that time.  Although this patient requires additional rehabilitation, this can be provided in the community setting with home and outpatient therapy services.  All told, continued skilled nursing facility services are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee requested authorization and coverage of allogenic stem cell transplantation combining high-dose Melphalan and autologous stem cell transplant with non-myeloablative PBSC allografting. The Health Plan denied the enrollee's request indicating that the requested therapy is considered investigational for the treatment of the enrollees multiple myeloma. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three CHDR physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three CHDR physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential mental health and substance abuse treatment for his alcohol use disorder.   The physician reviewer found that based on the presentation and concerning history of alcohol consumption, this patient was at high-risk for complicated alcohol withdrawal.  Thus, a supervised detoxification was indicated.  During visits with his primary care provider the patient was tachycardic.  He was diagnosed with and treated for hypertension.  He was demonstrating psychiatric symptoms that prompted prescription of an antidepressant medication.  Upon presentation to the treatment facility, the patient was intoxicated.  His blood pressure was elevated.  He reported past withdrawal symptoms of nausea, shakes and sweats.  He had abnormal liver function tests and a microcytic finding on blood count.  He was treated with a chlordiazepoxide taper.  In sum, detoxification services in a residential setting were medically indicated and were expected to improve the patients condition.  Therefore, initial residential placement was medically necessary.  However, the medical records do not demonstrate the continued necessity of treatment in a 24-hour supervised.  The patient was motivated for recovery and had a supportive family.  He did not have legal sequelae from his drinking.  He did not use other substances.  He did not have a co-occurring psychiatric condition that would necessitate treatment in a setting other than the outpatient venue.  Of further significance, the patient had not pursued chemical dependency treatment in a less restrictive setting, such as community-based programming, outpatient services or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  All told, residential mental health and substance abuse treatment initially was medically necessary, but not thereafter.  Final Result: The reviewer determined that that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for multidisciplinary rehabilitation therapy for treatment of the enrollee, who is status post traumatic brain injury. Findings:  The physician reviewer found that this patient demonstrates behavior and functional limitations consistent with a severe brain injury.  He is considered unsafe, and he is unable to participate within an outpatient supported living environment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee has requested sacroiliac joint arthrography and injections for treatment of sacroiliac joint pain.  Findings:  Two physician reviewers found that review of the medical literature yields mixed reviews in the use of sacroiliac joint injections for management of chronic low back pain. It seems that they do have a diagnostic component. It appears that in selected cases, sacroiliac joints can be of great help in the management of intractable pain due to joint dysfunction. In fact, this patient has had documented improvement from the injections.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee requested germline testing (MLH-1 dup/delete variant (CPT 81294); MSH-2 dup/delete variant (CPT 81297); MSH-6 dup/delete variant (CPT 81300) and PMS-2 dup/delete variant (CPT 81319)) for medical evaluation of his cystic sebaceous tumor.  Findings:  Two physician reviewers found that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient has a personal history of a sebaceous adenoma with loss of MSH-2 expression, presence of MLH-1 expression, a family history of a constellation of cancers that are strongly suggestive of possible Lynch syndrome or Muir-Torre syndrome, and is of maternal and paternal Russian Ashkenazi Jewish descent.  Full gene sequence testing for all four genes in question was authorized.   Therefore, the additional request for testing of deleted and duplicate variants of the four genes are not clinically indicated at this time. Testing of the deleted and duplicate variants may potentially be indicated, if the full sequence testing of all four genes is negative. As such, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.