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

A 48-year-old female enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of her stage IIA, T1N1 right breast invasive ductal carcinoma.  Findings:  Two physician reviewers found that oligometastatic disease is a well described phenomenon in breast cancer in a distinct subtype of patients who present with an intermediate state of cancer spread between localized and widespread metastasis (Corbin, et al). This patients clinical history is consistent with oligometastatic disease since she has only one site of disease and has lived for a prolonged period of time after her first presentation of metastatic disease. In the medical literature, SBRT enables highly focal treatment of cancer, allows for a higher dose effect to the tumor, and provides improved local control of tumors over 3D conformal techniques. Based on the study by Milano and colleagues, patients with oligometastatic disease who are most likely to derive a benefit from SBRT are those with young age, good performance status, metastasis less than 5cm, and a prolonged disease course. The records document that this patient meets all of these criteria. As there is supporting clinical evidence to support the use of SBRT over conventional techniques for treatment of this patients medical condition, the requested therapy should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 22-month-old male enrollee has requested authorization and coverage for TREX1 genetic testing for evaluation of the enrollee, who has a history of global developmental impairment with associated cerebral calcifications.  Findings:  The physician reviewer found that the submitted documentation supports the requested testing in this patients case.  This patient has clinical features of Aicardi-Goutieres syndrome, including low birth weight, nystagmus, strabismus, progressive microcephaly, spasticity, periventricular and basal ganglia calcifications, and severe global delays.  Per the submitted medical records, the patients TORCH titers were reportedly normal, making Aicardi-Goutieres syndrome a likely diagnosis.  This disorder results in significant health problems.  Thus, establishing the diagnosis is indicated in this patients case.  All told, the requested TREX1 genetic testing is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Velcade in combination with Xpovio and low dose dexamethasone. Xpovio is U.S. Food and Drug Administration (FDA) approved for the treatment of relapsed or refractory multiple myeloma in combination with dexamethasone in patients who have received at least four prior therapies, and are refractory to at least two proteasome inhibitors, at least two immunomodulatory agents, and an anti-CD38 monoclonal antibody. This patients disease has reportedly progressed despite treatment with Ninlaro, Revlimid, and dexamethasone as well as daratumumab and pomalidomide. Bahlis and colleagues reported on a phase 2 trial of 45 patients with relapsed or refractory multiple myeloma receiving Xpovio with Velcade and low dose dexamethasone (SVd). The authors found that this regimen produced high response rates without unexpected side effects. In addition, Grosicki and colleagues reported significant median progression free survival with SVd over Velcade with dexamethasone. The triplet combination of SVd is thus appropriate for this heavily pretreated patient with symptomatic disease. Given this support, the requested Velcade in combination with Xpovio and low dose dexamethasone are medically necessary for this patient. Final Result: The reviewer determined that the requested medication regimen 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 subspecialty certifications in medical oncology and hematology 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 patient has requested authorization and coverage for Monovisc injections. The ERCI Institutes Health Technology Assessment for Viscosupplementation for Treating Osteoarthritic Knee Pain concluded that evidence remains inconclusive on which patient populations are likely to benefit most from hyaluronic acid injections. Evaluation of eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients, but questions remain about the most effective formulations and whether hyaluronic acid injections should be combined with other agents to increase effectiveness. Peer-reviewed literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports-related chondropathy has yet to be fully assessed. The ideal indication in the knee seems to be moderate femorotibial osteoarthritis without swelling. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. This patient presents with a history of chronic left knee pain. He is status post left knee arthroscopy, partial lateral meniscectomy, and chondroplasty of the lateral tibial plateau in 2017. He had a return of left lateral knee pain with an increase in his activity level. Conservative treatment has included physical therapy, home exercise program, NSAIDs, platelet-rich plasma injection, corticosteroid injection, and stem cell injection without adequate relief of symptoms. He underwent Monovisc injection on 11/27/18 with the most significant relief to date, but his pain was reported grade 8/10 after only five months. Based on the records provided for review, there is a lack of documentation that this patient has significant moderate to severe osteoarthritis of the left knee. There is no current left knee examination or post-operative imaging reports supporting a diagnosis of moderate to severe osteoarthritis. Additionally, the records suggest the patient did not achieve six months of sustained improvement with the prior Monovisc injection to support a repeat injection consistent with evidence-based medical guidelines and literature. Therefore, the requested Monovisc injections are not medically necessary for treatment of this patients 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 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

A 52-year-old male enrollee has requested partial knee replacement surgery for the treatment of his right knee pain. Findings:  The physician reviewer found that total knee replacement is an accepted procedure with proven durability and excellent outcomes. More recently, there has been an increased interest in unicompartmental replacement in the treatment of arthritis limited in extent. It has been recommended for medial compartment arthritis, with a fully intact anterior cruciate ligament. Unicompartmental replacement is not recommended in cases with anterior cruciate ligament deficiency since this can lead to increased damage to the other compartments, and it is also not indicated in the presence of patellofemoral arthritis. There has been some development of bicompartmental replacement prostheses, but there is a lack of sufficient published information to discuss them. In this case, there is documentation of arthritis in the patellofemoral and lateral joints. In addition, the presence of documented anterior cruciate ligament laxity would tend to increase the risk of additional degeneration in the medial compartment in the future. These would all contribute to the need for total, rather than partial, replacement, as was discussed by the orthopedic consultants noted in the record.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that this patient had been in outpatient treatment for his substance problems in the past. Following his outpatient treatment, he had several suicide attempts. His outpatient treatment had been ineffective at managing his needs. During his RTC treatment, his mood was depressed upon admission, then improved a few weeks into treatment, but worsened towards the last few weeks, to the extent that he was diagnosed with dysthymia and antidepressant medications were again recommended. In cases such as this, an evidence-based, objective, instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is useful in determining the necessary level of care. This patient had a composite score of 25-27, which correlates with a treatment intensity level of five which is Non-Secure, 24-hour psychiatric monitoring, such as an RTC. In addition, his score of major on dimension three is an independent qualifier for level five. This indicates that upon admission he met criteria for a RTC stay. The patient appeared to make some progress in treatment. However, during the last few weeks of treatment, his mood appeared much worse and he and his family were unwilling to initiate a recommended medication trial. Due to these important factors, it appears that his progress was not great enough in treatment to warrant him being placed in a less restrictive setting prior to his discharge. His untreated dysthymia, past impulsive and dangerous behaviors, past reckless substance abuse with overdoses, and history of numerous suicide attempts continued to place him in an extremely high risk category for another suicide attempt. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Since this patient did not appear to have adequate treatment progress, it appears that it would not have been safe to discharge him to a lower level of care until the date of service at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Upheld

A 46-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that Lam and colleagues found that for patients with treatment resistant depression, TMS appears to provide improved health outcomes in short-term treatment studies. However, the relatively low response and remission rates, short durations of treatment, and the lack of studies with systematic follow-up suggest that further data are needed before TMS can be considered a first-line monotherapy for treatment resistant depression. Similarly, Gershon and colleagues reported positive responses of TMS as an antidepressant treatment, but cautioned that the need for verification and standardization of best practices and type of patient that would benefit still remain unknown. As such, the use of TMS in this patients care was not likely to provide him with superior results when compared with standard proven therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization for Dynamic Temporal and Tactile Cueing (DTTC) services five times a week for treatment of the enrollees severe childhood apraxia of speech. Findings:  The physician reviewer found that the submitted documentation does support the medical necessity of the requested services. Maas and colleagues have studied current trends in treatment for childhood apraxia of speech (CAS) and found that motor-based interventions can produce gains in speech production abilities in children with CAS. Their study found that, at present, a DTTC-type integral stimulation approach has the strongest evidence base, with replicated evidence of efficacy from several well-controlled single-case experimental design studies from different, independent research groups. The literature supports that the use of Dynamic Temporal and Tactile Cueing (DTTC) is efficacious for patients with apraxia of speech. The submitted documentation shows that the patient continues to use his letter board. Additionally, the records show that the patient scored in the less than 0.1 percentile for articulation/phonology and, as of July 2018, continues to have severe sound production difficulties and mild groping. As the patient has been in standard speech therapy since 2015, two times per week, and continues to have severe sound production difficulties, the use of DTTC is a reasonable approach to try to increase his verbal communication. The frequency of this therapy would be appropriate at five times per week, with a re-assessment of efficacy at six months. Therefore, the requested Dynamic Temporal and Tactile Cueing services five times per week is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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 physical medicine & rehabilitation, with sub-specialty certification in pediatric rehabilitation medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested posterior tibial nerve stimulation (PTNS) for treatment of her overactive bladder.  Findings:  Two physician reviewers found that this patient has previously undergone surgery for incontinence without substantial improvement. Subsequently, her symptoms persisted after removal of the transvaginal tape. Given that this patient has failed surgery and medical therapy, additional data on her medical condition is needed via complex cystometrics, cystoscopy and video urodynamics to support an indication for the requested PTNS. Accordingly, the requested PTNS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

The mother of an 11-year-old male enrollee requested authorization and coverage of interferon injections for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees lymphangiomas.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy. One CHDR physician reviewer concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy. Because two of the three physician reviewers concluded that he requested therapy is likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee requested authorization and coverage of out-of-network care from a neuropsychologist for the treatment of insomnia.  The Health Plan denied the enrollees 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old male with a history of hepatitis C. Despite 12 weeks of Peg-Intron and ribavirin therapy the patients viral count did not drop by two logs. The patient has requested authorization for continued therapy. The Health Plan has denied this request on the basis that the requested therapy is not likely to be of benefit and therefore, is not medically necessary.The Health Plans denial should be upheld. The submitted records indicate the patients viral count did not drop by two logs after 12 weeks of Peg-Intron and ribavirin therapy. There is no prospective, peer-reviewed study demonstrating that continued therapy is beneficial in this group of patients. The article cited above by Fried shows that patients who do not experience a two log drop after 12 weeks of therapy only have a 3% chance of clearing the virus after a full course of therapy. Thus, continuation of Peg-Intron and ribavirin is not likely to benefit the patient and is not medically warranted. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An male enrollee has requested authorization and coverage for anesthesia during magnetic resonance imaging (MRI) of the brain. The patients records support an ASA preoperative physical status classification score of 2. In this clinical setting, intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in practice and in the research, given the patients low preoperative ASA physical status classification score. The Health Plan has authorized a large bore MRI with sedation, which should be appropriate in this clinical setting. Thus, the requested authorization and coverage for anesthesia during MRI of the brain, is not medically necessary for evaluation of the 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for shoe insert (custom molded orthotics). The Health Plan has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees rheumatoid psoriatic arthritis. A review of the record indicates that the enrollee has been diagnosed with rheumatoid arthritis, psoriatic arthritis and capsulitis of the first metacarpophalangeal joint (MPJ). The provider note reported the enrollees old orthotics have bottomed out and no longer offer utility. The provider reported the enrollee is in need of new orthotic appliances because of their arthritic status and chronic pedal pain. The provider reported the enrollee has had these devices previously approved and will return to the office for orthotics casting pending approval. The submitted documentation supports the medical necessity of the requested devices. It is established in the progress note that the patient suffers with psoriatic and rheumatoid arthritis to bilateral feet as well as capsulitis to the first metatarsophalangeal joint on the left side. Orthotics are commonly utilized to combat foot pain caused by arthritic conditions. Functional custom molded orthotics provide significant support to otherwise unstable or painful joints that help reduce pain. Custom molded orthotics may also incorporate certain pads and fabrications in order to accommodate pain below the first metatarsophalangeal joint. Therefore, the requested custom orthotics are medically reasonable and necessary for treatment of this patient.Final Result: The reviewer determined that the requested devices are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.