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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for inpatient rehabilitation.Findings: Three out of three physician reviewers found that the requested treatment of inpatient rehabilitation is likely to be more beneficial than any available standard treatment for the patients medical condition, complex regional pain syndrome in both feet and both hands.A review by Weissman and Uziel considered current treatment options for Pediatric complex regional pain syndrome (CRPS) and concluded that exercise and physical therapy are the main treatment cornerstones of all pediatric CRPS patients. A review by Hoffart and Wallace stated that the standard of care for pediatric amplified pain syndrome patients is multidisciplinary, which can be done through a multidisciplinary clinic or through appropriate referrals for counseling and therapies. They noted that evidence of the effectiveness of intensive interdisciplinary pain rehabilitation (IIPR) continues to accumulate.In this case, the patient has a diagnosis of an amplified pain syndrome, specifically CRPS of the hands and feet. The patient has tried and failed the standard of care, which includes a trial of medication management with multiple different classes of drugs. The patient has also tried injection therapy with little benefit as well as outpatient physical therapy and behavioral pain management. The patients current pain management provider has recommended that the patient warrants an intensive inpatient pain rehabilitation approach based on the severity of his disease and his failure to respond to standard treatments. Under these circumstances, the requested treatment of inpatient rehabilitation is likely to be more beneficial than any available standard treatment for the patients medical condition, complex regional pain syndrome in both feet and both hands.Final Result: The reviewer determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in neurology and is actively practicing. Physician reviewers 2 and 3 are board certified in anesthesiology, with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for any or all of the chiropractic services provided by Dr. Douglas DeSalvo on 9/21/20, 9/30/20, 10/01/20, 10/05/20, 10/07/20, 10/09/20, 10/12/20, 10/16/20, 10/19/20, 10/23/20, 10/26/20, 10/30/20, and 11/02/20.Evans and colleagues found, Spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months. Additionally, Goertz and colleagues concluded, Chiropractic manipulative therapy (CMT) in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care. In this case, the patient presented with right shoulder and lower back pain. The patient has chronic pain and has received chiropractic care. It was reported that the patient had 50% improvement with chiropractic care. Based on ongoing improvement with chiropractic care and frequent flare up of her symptoms chiropractic therapy was appropriate. Therefore, chiropractic services provided by Dr. Douglas DeSalvo on 9/21/20, 9/30/20, 10/01/20, 10/05/20, 10/07/20, 10/09/20, 10/12/20, 10/16/20, 10/19/20, 10/23/20, 10/26/20, 10/30/20, and 11/02/20 were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in chiropractic 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Relationship Development Intervention (RDI) therapy for treatment of the enrollees medical condition.    Findings:  Two physician reviewers found that according to the American Academy of Pediatrics on management of children with autism spectrum disorders RDI focuses on activities that elicit interactive behaviors with the goal of engaging the child in a social relationship so that he or she discovers the value of positive interpersonal activity and becomes more motivated to learn the skills necessary to sustain these relationships. Some reviewers have praised the face validity of this model, which targets the core impairment in social reciprocity. However, the evidence of efficacy of RDI is anecdotal; published empirical scientific research is lacking at this time. The research supporting RDI is limited. However, the research for applied behavioral analysis (ABA) therapies is more extensive and demonstrates that ABA is effective. At this time, RDI has not been established in the peer-reviewed literature as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  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:   One reviewer is board certified in pediatrics and is actively practicing.  One reviewer is board certified in child neurology and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is 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 authorization and coverage for factor II (prothrombin) DNA analysis laboratory testing. Findings:  Three physician reviewers found venous thromboembolism is common problem, with multifactorial causation. The G20210A mutation is a gain-of-function mutation that increases the prothrombin level to 30% above normal levels. With regards to patients who are positive for prothrombin G20210A and have a positive family history of clotting, the risk of venous thromboembolism increases three-fold to four-fold over the general population risk. This risk is higher when the venous thromboembolism occurred at a younger age or when there are multiple affected family members. In this patients case, the records document a family history of a clotting disorder in both his sister and maternal grandmother. His personal history is significant for right upper extremity deep vein thrombosis at a young age. The results of this testing are likely to impact the management of this patient. The treating provider noted that the results of the testing may impact whether the patient continues anticoagulation. Thus, factor II (prothrombin) DNA analysis laboratory testing is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 and 3 are board certified in clinical genetics and genomics 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

A thirty-nine year-old female diagnosed with stage IC endometrial carcinoma of the ovary is requesting authorization for a PET scan.  Reviewers Findings:The reviewing physician found that the PET scan has not been proven to be more effective than standard imaging studies for the staging of ovarian cancer.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to the 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 life expectancy less than 12 months due to non-liver-related conditions. Patients with cirrhosis are reported to be high priority for treatment. Per the guidelines, cirrhotic patients who have failed Sovaldi, peg-interferon, and ribavirin should be treated with a different regimen. Treatment with Harvoni and ribavirin for 24 weeks is recommended based on a study of 352 prior treatment failures, with cure rate of 95-98% (Reddy, et al). Treatment with Sovaldi with Viekira Pak and ribavirin is not recommended. The requested regimen of Sovaldi with Viekira Pak and ribavirin, is only recommended by AASLD/IDSA guidelines for patients who have failed an NS5A inhibitor and who have both NS3 and NS5A resistance-associated variants, which is not reported in this case (Poordad, et al).  For these reasons, the request for Sovaldi is not supported as medically necessary for the treatment of this patients hepatitis C infection.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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for the evaluation of her medical condition.   Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis allows radiologists to separate architectural distortion or mass from normal, dense glandular breast tissue.  This has resulted in a decrease in callbacks and increase in detection of small cancers.  Based on the medical literature, the addition of breast tomosynthesis to two-dimensional mammography was likely to be more beneficial to the patient than two-dimensional mammography alone.  Final Result: Two reviewers determined that the services at issue were 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:  All three reviewers are board certified in diagnostic radiology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Synvisc One injection in the right knee every six months and ongoing for treatment of the enrollees osteoarthritis in the right knee. Findings:  The physician reviewer found that studies concluded that there is a general lack of reliable evidence that any specific brand of viscosupplementation agents is superior to others. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. This patient presented with recurrent right knee pain that was functionally limiting. Clinical examination findings were consistent with imaging evidence of right knee osteoarthritis, with complete collapse of the medial joint space. There is a lack of evidence in the submitted record that the patient failed to adequately respond or was intolerant of the preferred viscosupplementation agents, Euflexxa or Orthovisc. Accordingly, the submitted records do not show a compelling rationale presented to support the medical necessity of Synvisc One over Orthovisc or Euflexxa. With regards to the request for future injections, the medical necessity of future viscosupplementation injections is based on response to the prior injection lasting for at least six months. Accordingly, at this time this request cannot be established for ongoing future injections. For these reasons, Synvisc One injections to the right knee were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Praluent for treatment of the enrollees familial hyperlipidemia, coronary artery disease, and ischemic chest pain. Findings:  The physician reviewer found that based on the records provided, the patient presents with hyperlipidemia and intermittent chest discomfort but no provokable ischemia on stress testing and no obstructive coronary disease on angiography. Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease as evidenced by myocardial infarction, coronary bypass, provokable ischemia on stress testing, stroke, or transient ischemic attack who require additional lowering of LDL cholesterol. This patient does not meet these criteria. Familial hyperlipidemias require elevated LDL cholesterol levels that significantly exceed 180 mg/dL as well as a combination of physical examination findings such as arcus cornealis below the age of 45 or tendon xanthomatas, a strong family history of coronary disease with diagnosis in a relative younger than 50 years in a second-degree relative or younger than 55 years in first-degree relatives, and documented genetic defects related to cholesterol metabolism according to published criteria. PCSK9 inhibitors have not been studied in other patient populations. Moreover, current guidelines endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this clinical setting.  Finally, this patients LDL is close to goal on statin medication and the addition of Zetia in this setting has been shown to result in incremental reduction in LDL cholesterol levels with improvement in outcomes.  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 cardiovascular disease 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 47-year-old female enrollee has requested lap band surgery (laparoscopic banding) for treatment of her obesity. Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested lap band surgery (laparoscopic banding). The patient meets the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of 40, or a BMI of at least 35 with severe co-morbid conditions. This patient has a BMI above the indicated criteria and hypertension, meeting the definition of clinically severe obesity. The patient has also failed dietary efforts and a completion of a multidisciplinary evaluation did not reveal any obvious barriers to surgery. All told, the medical necessity of the requested procedure has been established.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of hormone pellet implants. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the enrollees hormone replacement.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

This 63-year-old man has prostate cancer. He experienced a rise in PSA from 4.0 in June 2001 to 11.5 in November 2003. Biopsies from the left side revealed Gleason score of 5+4=9 in 5/6 core biopsies. Biopsies from the right side revealed Gleason score of 5+4=9 in 6/6 core biopsies. Based upon Partins Tables, the risk of capsular penetration is 41%, the risk of seminal vesicle involvement is 15%, and the risk of pelvic lymph node involvement is 38%. The urologist staged the patient as T2c while the radiation oncologist recommended two to three years of neoadjuvant hormone therapy (NHT) along with radiation therapy to the prostate and regional lymphatics followed by a boost of radiation to the prostate gland. The patient wishes to receive intensity modulated radiation therapy (IMRT) rather than 3-dimensional conformal radiation therapy (3D CRT). The Health Plan has denied authorization and coverage for IMRT on the basis that it is not medically necessary.IMRT is a more precise therapy compared to 3D CRT. IMRT can deliver 8000 cGy to the prostate, while 3D CRT can deliver 7200 cGy to the prostate. However, it is likely that the patients cancer is not limited to his prostate. There is a 38% chance of lymph nodes being positive. Thus, it is not sufficient to treat the prostate only. Presently, diagnostic imaging is incapable of outlining the lymph nodes in the pelvis and therefore, IMRT will be useless for these potentially involved targets. IMRT is superior to 3D CRT only when the disease is confined to the prostate. There is a strong likelihood that the cancer involves the patients pelvic lymph nodes as well. For patients such as this patient, 3D CRT is just as effective without any change in the prognosis.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female enrollee has requested Genium Microprocessor knee for treatment of her right lower extremity post amputation for osteosarcoma.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested Genium Microprocessor. This patient would benefit from the use of a microprocessor controlled knee system. The patient is young, healthy, active, and meets accepted criteria for such a system: adequate cognition and cardiovascular reserve, the ability and need to ambulate faster and further and the need to ambulate on stairs and uneven terrain. Most importantly, the patient has a need for improved safety and an immediate stop to falling. The Genium Microprocessor controlled knee will assist in her limited social and physical activities. Multiple studies have shown a more natural gait pattern and improved biomechanics of gait using the microprocessor controlled knee and the Genium system in particular. All told, the medical necessity of the requested equipment has been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested clobetasol foam for treatment of her rash. Findings: The physician reviewer found that in this patients case, the medication at issue was not medically necessary for treatment of her contact dermatitis on her legs. The patient used clobetasol cream without improvement prior to trying the clobetasol foam but given that she did not see improvement with the cream formulation, the foam formulation, of the same medication, would not have been indicated as an alternative therapy. Allergic contact dermatitis will self-resolve over time. Alternatively, a more aggressive therapy such as oral steroids, could have been prescribed.  Therefore, clobetasol foam used for treatment of the patients contact dermatitis was not medically necessary.Final Result: The reviewer determined that the medication at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in dermatology 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: Overturned

A 58-year-old male enrollee requested authorization and coverage of the medication Tegaserod. The Health Plan  denied the request indicating that the requested medication is considered investigational for the treatment of the enrollees dyspepsia.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested medication is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested medication is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested medication is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.