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

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation of the bilateral sacroiliac joints for treatment of her medical condition.   Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The provider reported that the patient experienced improvement from prior radiofrequency ablation.  However, the duration was not mentioned.  The patient stated it lasted a specific length of time, but this is not corroborated in the office visits.  A request for fusion of the sacroiliac joint was made by the provider.  Furthermore, while the patient states she underwent conservative care, it is unclear this was directed to the sacroiliac joint.  Per the medical literature, radiofrequency ablation is done after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage.  This was not included in the documentation available for review.  Therefore, the superior effectiveness of radiofrequency ablation of the bilateral sacroiliac joints has not been established. Final Result:  Two 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:  All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for breast cancer screening. Findings: Two reviewers found that the patient was evaluated with screening mammogram and digital breast tomosynthesis. The report noted stable findings with no evidence of cancer. The Health Plan has denied reimbursement for digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is evidenced base support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocols was likely to be more effective to the patient than had her examination been performed using two dimensional imaging alone. Final Result: Two 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.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The conservator of a 21-year-old male enrollee has requested for an inpatient, post-acute traumatic brain injury program for physical, occupational, speech and vocational therapies for treatment of the enrollee status post traumatic brain injury. Findings:  The physician reviewer found that the standard care for patients with post-traumatic memory, judgment, and cognitive impairments includes multi-disciplinary therapies such as occupational therapy, speech therapy and physical therapy as appropriate, in order to facilitate safety and recovery to an optimal level of independence. The appropriate level of care is often patient specific and should include considerations of the patients level of safety, level of in-home support and strategies for community integration. The literature demonstrates that patient care in comparable cases is often best provided in a structured, inpatient setting. The peer reviewed medical literature has also demonstrated that recovery rates are often better in young adults, than in older individuals. In this case, the patients records indicate ongoing improvements, which can be anticipated to continue with appropriate future treatment. All told, ongoing care in an inpatient, post-acute traumatic brain injury program is appropriate and medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza. Findings: Two of the three physician reviewers found that Afrezza inhalation powder is a rapid-acting Technosphere insulin administered via a breath-powered oral inhaler to patients with diabetes requiring prandial insulin.  Although it achieved the pre-specified non-inferiority margin of 0.4% as compared to injections of rapid acting insulin in a recent trial, patients with type 1 diabetes who received Afrezza demonstrated less reduction in hemoglobin A1c levels per the review by researchers. In this patients case, the records do not establish the superiority of Afrezza as compared to injectable insulin. Therefore, Afrezza is not likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The mother of a three-year-old male enrollee has requested continued partial hospitalization services for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted clinical evidence does not establish the medical necessity of continued partial hospitalization services. The patient has clearly made significant clinical gains in the partial hospital program. These gains are sufficient to allow him to return to a less restrictive mode of therapy. As such, the patient can be appropriately treated at a less restrictive level of care and no longer requires partial hospitalization services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni (ledipasvir 90 mg/sofosbuvir 400 mg for treatment of the enrollees hepatitis C virus.  Findings: 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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, genotype 1 patients who have failed PEG-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage (Afdhal, et al, Lawitz, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.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 physician 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 59-year-old male enrollee has requested a PET scan for evaluation of his pulmonary nodules and mediastinal lymph nodes.  Findings:  The physician reviewer found that a PET scan may be positive in both inflammatory and malignant disease. It can also be negative in some malignancies. As such, a PET scan was not able to definitively determine the etiology of the patients left lower lobe densities. A biopsy would have been the next procedure of choice. If a malignancy was found on biopsy, a PET scan might then have been helpful in the staging evaluation. However, a PET scan prior to lung biopsy was not clinically useful or indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Eversense continuous glucose monitor (CGM). The Eversense real time CGM system consists of a subcutaneously inserted sensor, a wearable transmitter, and a smartphone application. The sensor longevity is achieved using multiple approaches, including the chemical structure of the glucose binding polymer, the platinum coating, the dexamethasone acetate eluting ring, and the subcutaneous position in comparison to transcutaneous real time CGM systems. The U.S. Food and Drug Administration (FDA) approved the Eversense CGM in 2018. There are multiple peer-reviewed studies and published literature attesting to the Eversense CGM accuracy, and its superiority to the Dexcom and the Freestyle Libre CGM devices. In a recent study that compared the three CGM systems, the point accuracy of the Eversense was significantly better than two other CGM systems. In this case, the patient has had difficulties with the Dexcom and Freestyle Libre CGM in terms of accuracy and in maintaining the sensor in place, given his active lifestyle at work and during exercise. The patient also has documentation of hypoglycemia unawareness. The Eversense CGM is implantable subcutaneously, which also supports superior accuracy when compared to Dexcom and Freestyle Libre CGM devices, and helps keep the sensor in place. All told, the requested Eversense CGM is medically necessary for 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 subspecialty certification in diabetes, endocrinology 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

A 27-year-old male has requested bilateral reduction mammaplasty, bilateral mastectomy, and bilateral nipple/areola reconstruction for treatment of his persistent gender dysphoria.   Findings:  The physician reviewer found that based on review of the available records, the patient has documented gender identity disorder (GID) and has requested coverage for removal of both breasts. A letter from one provider states that the patient has a history of gender dysphoria and that the patients condition would likely improve with surgery. The documentation from the plastic surgeon only states that the patient has a diagnosis of trans-sexualism and that the patient would like to have both breasts removed. The American Society of Plastic Surgeons (ASPS) defines cosmetic surgery as a procedure being performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. By contrast, the ASPS consider reconstructive surgery to be performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Although the procedure is generally performed to improve function, it may also be done to approximate a normal appearance. Thus, there may be an indication for breast reduction or mastectomy if a reconstructive goal is adequately defined. However, this patients records do not establish an indication for a reconstructive medical procedure. Specifically, the provider does not provide adequate reasoning for reconstruction and only states that the patient requests breast removal for a diagnosis of trans-sexualism. The provider does not detail the patients functional problem and degree of severity. The patients social worker states the requested services will improve the patients comfort within his own body, but this documentation does not provide adequate support to establish the services as medically necessary. Further, a task force from the American Psychiatric Association (APA) has not provided definitive support for specific surgical treatment in patients with GID. The APA noted that, [T]here is a critical need for an APA Position Statement on the Treatment of GID, and given the time it will take to develop treatment recommendations, a position statement should precede the development of recommendations. All told, the requested bilateral reduction mammaplasty, bilateral mastectomy, and bilateral nipple/areola reconstruction, have not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested a three week outpatient day treatment program for comprehensive interdisciplinary pain management for the treatment of her medical condition. Findings:  The physician reviewer found that at this time, the standard of care for long-term management of fibromyalgia remains medications, including analgesics, and skilled outpatient PT graduated to an active, self-directed home exercise program. The medical literature does not yet recognize the efficacy of weeks of outpatient day rehabilitation in the treatment of fibromyalgia.  Also, comprehensive pain management rehabilitation programs have not yet demonstrated better long-term pain and quality of life outcomes than traditional fibromyalgia treatment.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested speech therapy for treatment of the enrollees autism and mixed receptive/expressive language disorder.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested therapy.  This patient presents with autism and mixed receptive/expressive language disorder. The speech therapists reassessment during a specified time noted that he was partially able to understand questions concerning a short story and that he had expressive and receptive aphasia. This reassessment established that the patient was responding positively to speech therapy intervention. Speech therapy is consistent with the standard of care in this setting. Further, in a controlled study comparing autistic children who did and did not receive speech therapy, those that did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner et al). According to the American Speech-Language Hearing Association (ASHA) report, all autistic children can benefit from speech therapy and emphasizes that age, either early or late in life, is not a barrier to speech therapy.  Thus, based upon the available peer-reviewed evidence as well as the patients documented progress with prior therapy, he has the potential to achieve further improvement with continued speech therapy. Therefore, it is medically necessary for this patient to receive speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee requested authorization and coverage of the prescription medication aricept for the treatment of memory loss.  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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested for robotic surgery for treatment of her ovarian mass. Findings:  Three physician reviewers found that the laparoscopic approach is not recommended due to the inability to adequately assess for spread, or to debulk possible tumor implants.  If this is in fact a fibroid or a benign ovarian mass, at this time the use of the robotic approach is also not the standard of care. The additional size and number of ports used for the robotic approach compared to standard laparoscopy could actually increase her risk of pain and scarring. Thus, the robotic approach is not uniformly appropriate for most gynecologic abdominal procedures.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested endovascular therapy for treatment of the enrollees brain aneurysm, non-ruptured.  Findings: The physician reviewer found that the medical literature supports the requested services in this clinical setting. The patient has an aneurysm that is 1 mm below what is recommended for endovascular intervention. She was also recently diagnosed with breast cancer. The provider noted that the patient required operative intervention for treatment of her breast cancer. However, the surgery will put her aneurysm at higher risk of rupture. In addition, the aneurysm is slightly larger on the most recent imaging compared to a previous imaging (6 mm versus 5 mm). Given these additional circumstances as well as the anticipated stressors of surgery and potential for blood pressure spikes with intubation for non-aneurysm surgery, the requested services are both medically indicated and within standard practice. All told, the requested endovascular therapy is medically necessary for treatment of this patient. 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 neurological 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: Overturned

The parent of a 10-year-old male enrollee has requested group occupational therapy, once per week for treatment of the enrollees Aspergers disorder.  Findings:  The physician reviewer found that this patient has been diagnosed with Aspergers syndrome, an autism spectrum disorder (ASD). The standard of care adopted by the medical community as set forth by evidence based guidelines for treatment of patients with ASD by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) recommends occupational therapy in this setting. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The literature reveals that the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction and behavior. Studies have shown that OT prevents deterioration and provides significant improvements in activities of daily living (Case-Smith and Arbesman). In sum, OT is a standard of care modality for patients with ASD. In the case of this patient, there is documentation of fine motor difficulties. In light of these deficits and given his progress with therapy thus far, there is sufficient evidence to support the medical necessity of group OT since the date in question and forward.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female with left branchial arch syndrome (hemifacial microsomia) including microtia, mandibular hyperplasia, and secondary dental malocclusion. She was previously treated with external ear reconstruction and mandibular distraction osteogenesis. The patient is currently under consideration for treatment of residual dental malocclusion, mandibular asymmetry, left facial hyperplasia and cranial nerve palsy affecting lip competence. Her provider has recommended orthodontic treatment. The Health Plan has determined orthodontic treatment is not medically necessary for treatment of the patients medical condition.The patient is progressing through staged treatment of left hemifacial microsomia. A functional dental occlusion would be a primary goal of this treatment and she will need orthodontic therapy to achieve that goal. Orthodontic treatment may be the final modality necessary to establish a functional dental occlusion. However, if orthognathic surgery is needed in the future then orthodontic treatment will be coordinated with that surgical procedure. Orthodontic treatment is medically appropriate for treatment of the patients hemifacial microsomia and should be authorized. As such, I have determined that the requested treatment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested epidural spinal injections for medical treatment of her thoracic radiculitis.  Findings:  Three physician reviewers found that given that the patient has not responded with definitive relief from facet joint injections, with evidence of osteophyte complex and pain in the ribs with nerve cysts, epidural spinal injections are appropriate in this clinical setting. As such, epidural spinal injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old female enrollee has requested a magnetic resonance spectroscopy (MRS) of the brain for an evaluation of the enrollees tumor on brainstem. Findings:  Two physician reviewers found that MRS is widely utilized to differentiate tumor from non-tumoral entities and it has also been useful in the differential diagnosis of tumor type. While further studies of MRS are needed, there is evidence to suggest that the data derived from MRS may well guide the treatment plan, timing of treatment, and yield prognostic data in this clinical situation. There is no evidence that any other non-invasive modality is likely to provide the type of information obtained with MRS.