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 occipital nerve block therapy. A review performed by Barmherzig and Kingston evaluated the current evidence and recommendations for the diagnosis and management of patients with occipital neuralgia. The authors concluded that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. However, evidence is limited as most studies are noncontrolled. In this case, the patient presents with a history of chronic migraine headaches and occipital neuralgia for which they are being treated with abortive agents and prophylactic agents including Botox, Vyepti and Emgality. The most recent peer-reviewed literature does not support that occipital nerve blocks are superior to standard therapy for the treatment of this patients migraines and occipital neuralgia. Based on these findings, the requested occipital nerve block therapy is 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 anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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 Zejula for treatment of the enrollees ovarian cancer.  Findings:  The physician reviewer found that Ovarian cancer consists of several histologic types and treatment depends on specific tumor type. Adenocarcinoma/epithelial, if metastatic, is treated initially with a carboplatin based regimen. Follow-up regimens are determined by whether the tumor appears to be carboplatin sensitive or resistant. The U.S. Food and Drug Administration (FDA) recently approved the use of Zejula based on the results of the NOVA trial in patients with ovarian cancer with and without BRCA1 and BRCA2 mutation. The trial demonstrated that regardless of mutation status there was an improvement in progression free survival in platinum sensitive patients. Although not listed in National Comprehensive Cancer Network (NCCN) guidelines, the FDA has approved the use of Zejula in this clinical setting and therefore it is medically reasonable for the patient to receive this drug and continue until progression. For the reasons provided, the request for Zejula 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 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 49-year-old female enrollee has requested Reclast intravenous (IV) infusions for treatment of her osteopenia.Findings:  The physician reviewer found that according to  the American Association of Clinical Endocrinologists guidelines, intravenous bisphosphonates that are FDA-approved for osteoporosis should be covered for treatment of osteoporosis when the following criteria are met: there is no class contraindication or hypersensitivity to bisphosphonates, and there exists either demonstrated intolerance or contraindication to FDA-approved oral bisphosphonates and oral dosing regimens; or insurmountable issues related to absorption, compliance or dosing posture; or anatomic abnormalities or motility disorders of the esophagus or stomach that could interfere with passage or absorption of the medication; or when adequate trials of FDA-approved oral bisphosphonates result in fallen BMD and/or failure to suppress bone turnover (e.g., persisting high bone-turnover marker measurements). Although this patient clearly has a contraindication to Evista with a history of pulmonary embolism, there is no clearly documented contraindication to oral bisphosphonates. This patients history of GERD, coupled with use of proton-pump inhibitor medication is not an absolute contraindication to oral bisphosphonate use. Furthermore, the medical records submitted in this patients case do not document a fall in BMD or prior trial and failure with an oral bisphosphonate. As such, the patient does not meet generally accepted clinical indications for IV bisphosphonates.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage for compounded (Progesterone/Testosterone/Triest) hormone replacement cream for treatment of menopause.  The enrollees health plan denied the request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a sixteen year-old female with a history of depression, cutting behavior, eating disorder, polysubstance abuse, and suicidality are requesting authorization and coverage for residential treatment services.Reviewers Findings:  The reviewing physician found that there is no evidence that a comprehensive treatment plan or goals are in place, or that the patient experienced any significant activity.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 30-year-old female who has a history of menorrhagia and dysmenorrhea. She has an abnormal pelvic exam and pelvic ultrasound. Her uterus is enlarged and contains areas seen on the ultrasound, which are most likely myomas. She has failed medical management (birth control pills and pain medications). The patient has requested authorization for a hysterectomy. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.The patient has an enlarged uterus. The ultrasound showed abnormalities in the echo pattern of the uterus, which the radiologist diagnosed as probable early myomatous degeneration. Since the patients uterus is enlarged to a 12-weeks size it is reasonable to assume that this enlargement is secondary to uterine myomas. The patient has tried birth control pills to treat her menorrhagia; however, the birth control pills did not result in improvement. There is no evidence that increasing the dose of birth control pills or using Depo-Provera would improve menorrhagia in women with myomas. ACOG Practice Bulletin on Surgical Alternatives to Hysterectomy in the Management of Leiomyomas states that based on good and consistent scientific evidence, hysterectomy provides a definite cure for women with symptomatic leiomyomas. This bulletin also states that although endometrial ablation appears to be an effective option in controlling menorrhagia in women without leiomyomas, further studies are needed in women who have clinically significant leiomyomas.Therefore, because there is no evidence the alternative treatment options would be effective in this case and in light of ACOGs evidence that a hysterectomy would provide a definitive cure for this patient, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee requested authorization and coverage of the medication thalidomide for the treatment of ocular melanoma.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication thalidomide is likely to be more beneficial for treatment of the enrollees ocular melanoma than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX Reflux Management System for treatment of his gastroesophageal reflux disease (GERD). Two physician reviewers found that currently, there is a paucity of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. An evidence review concluded that the long-term safety and efficacy of LINX  both alone and in comparison to current GERD therapies  remains to be determined. In addition, another best-evidence review concluded that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments. Adverse events, such as erosion through the esophagus, have also been reported in the period after U.S. Food and Drug Administration (FDA) approval. Given these findings, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of your medical condition than any available standard therapy.  Final Result: Two 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. Applying Section 1317.1(a)(2)(A), the services provided were emergency medical services. Per the American Urological Association (AUA) and Endourological Society guidelines, a trial of spontaneous passage is reasonable in patients amenable to conservative therapy with less than 10 mm distal ureteral stones in whom pain is well controlled (Assimos, et al.). However, the records provided for review document that this patient reported significant pain when he presented to the emergency department. The AUA guidelines state that in these patients, clinicians should recommend ureteroscopy as first-line therapy. This patient underwent ureteroscopy as recommended by the AUA guidelines. Regarding stent placement, the AUA guidelines report that, Following ureteroscopy, clinicians may omit ureteral stenting in patients meeting all of the following criteria: those without suspected ureteric injury during ureteroscopy, those without evidence of ureteral stricture or other anatomical impediments to stone fragment clearance. In this case, given the presence of significant edema precluding completion of ureteroscopy and stone removal, ureteral stent placement was appropriate as recommended in the current guidelines and medical literature (Pradere, et al.). Overall, studies have shown that emergent ureteroscopy has a high success rate, with a low complication rate (Zargar-Shoshtari, et al.). A delay in treatment of this patients distal ureteral stone could have placed his health in serious jeopardy (Haas, et al.). For these reasons, the services provided were emergency services provided for the treatment of an emergent medical condition as defined by California law.Final Result: The reviewer determined that the services were emergency medical services 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 subspecialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injection to the left knee. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis. At issue in this case is whether the requested Synvisc injection to the left knee is medically necessary for treatment of the enrollees medical condition.Clinical practice guidelines from the Osteoarthritis Research Society International, American Academy of Orthopaedic Surgeons and American College of Rheumatology indicate that viscosupplementation does not produce clinically significant improvement as compared to placebo injections. None of these practice guidelines support the continued use of viscosupplements. Therefore the requested Synvisc injection is not medically necessary. Final Result: The reviewer determined that the requested treatment 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 anesthesiology 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: Overturned

The parent of a 14-year-old female enrollee has requested residential care services for the treatment of the enrollees mood disorder, parent-child relational problems, cannabis abuse and post-traumatic stress disorder, chronic. Findings:  The physician reviewer found that the evidence demonstrates that this patient did indeed need residential treatment at the time of admission and that this level of care was consistent with the American Psychiatric Association guidelines. However, based on her documented gains, she could have been safely discharged to a lesser level of care on the date in question. This date reflects the patients improvements documented on resident review. The patient could have been safely and appropriately discharged to a partial hospitalization program (PHP) for treatment of her ongoing therapeutic issues. The anticipated length of stay at PHP level of care would be eight to twelve weeks, but this is only an estimate and would depend upon the patients progress as determined by re-evaluation at two-week intervals.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested an insulin pen for treatment of her diabetes. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested insulin pen in this clinical setting.  There is evidence in the literature indicating that insulin pens are superior to use of insulin vials and syringes.  Insulin pens improve patient compliance and diabetes management.  Based upon the medical records, the insulin pen is medically appropriate to deliver meal insulin for this patient.  Her diabetes is suboptimally controlled, given her medical problems and poor insulin regimen.  This patient is active and self-adjusts her insulin dosage.  There is sufficient support for the use of an insulin pen in this clinical setting.  All told, the requested insulin pen is medically indicated for the management of this patients diabetes.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female has requested Forteo for the treatment of her osteoporosis. Findings:  The physician reviewer found that this patient was treated with two bisphosphonates for documented osteoporosis. She failed both treatments due to the gastrointestinal intolerance. The leading cause of discontinuing bisphosphonate therapy is gastrointestinal causes. Therefore, it was not unusual that the patient would have experienced a similar result leading to cessation of treatment. Based on the bone mineral density results, the patient had significant osteoporosis that required treatment. The patient was not able to tolerate once monthly bisphosphonate. She was on Actonel for a three month period and had to discontinue this medication due to the gastrointestinal side effects. The literature supports alternative treatments with other medications when bisphosphonates have failed. The failure of the bisphosphonate was not due to a decrease in the bone mineral density, but was due to the gastrointestinal intolerance. Given this, an alternative form of therapy is reasonable to prevent significant morbidity from osteoporotic fractures. Forteo has a different mechanism of action than the bisphosphonates and could certainly be an option for this particular patient. Not treating the patient with a medication targeted for treating osteoporosis would not be an option given the failure of the bisphosphonates. The risk of fracture for this patient with its attendant morbidity and mortality would be great given the results of the DEXA scan showing severe osteoporosis. Forteo is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested for a consultation with a neurologist for treatment of his back and leg pain and nerve pain. Findings:  The physician reviewer found that there are no neurological complaints or deficits. Given these factors, neurological evaluation is unlikely to add any new information regarding this patients symptoms. Neurological testing including electrodiagnostic testing (EMG/NCV) is also unlikely to add any significant information in the absence of any neurological deficits since there is little correlation between electrophysiological findings and actual pain.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: The reviewers determined that the service 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: the 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with myofascial pain syndrome. Magnetic resonance imaging (MRI) of the left shoulder revealed supraspinatus and infraspinatus tendinosis with minimal acromioclavicular osteoarthritis. MRI of the cervical spine showed multilevel disc desiccation, moderate to severe canal stenosis at C3-4, and mild canal stenosis at C6-7. The patient reported four years of constant left sided neck pain with radiation to the trapezius area, left medial arm, and middle finger. She also reported numbness in the same distribution as the pain. Physical examination findings included full strength in all major muscle groups of the upper extremities. Tenderness to palpation was noted over the left cervical paraspinous muscles, left trapezius muscle, and periscapular area with radiation to the left upper extremity. The patient has been treated with physical therapy and acupuncture, with no significant pain relief. She was also treated with a left acromioclavicular joint injection and biceps tendon injection with no relief. The patient has requested authorization and coverage for MRI of the back, shoulder, and pectoralis region. The Health Plan has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. At issue in this case is whether an MRI of the back, shoulder, and pectoralis region is medically necessary for the evaluation of the patients medical condition. This patient has had an MRI of the cervical spine and the left shoulder with no documentation of any significant change in symptoms since examinations. Nerve conduction study results were not noted in the medical records. The symptoms the patient exhibits can be seen with brachial plexopathy, but the hallmark of that diagnosis is a positive nerve conduction study. While radiculopathies tend to be sensorimotor, brachial neuritis is often motor-dominant. Electrophysiological studies help in the confirmation of diagnosis, extent of lesion, and prognostication. Due to the lack of a nerve conduction study and lack of documentation of significant change in symptoms since the MRI studies, the requested MRI of the back, shoulder, and pectoralis region is not medically necessary for the evaluation of this patient. 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 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.