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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  Researchers noted that breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.   Final Result: Three 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: Overturned

The parent of a two-year-eight-month-old male has requested speech therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS).  Findings:  The physician reviewer found that autism spectrum disorder (ASD), including pervasive developmental disorder, not otherwise specified (PDD-NOS) is a complex neurological disorder with characteristic deficits in speech/language and social interaction. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach and including speech therapy among other therapies. Children on the autistic spectrum often have significant deficits in speech and language, as well as with social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these patients, are most appropriate. The more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. All told, the requested speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee has requested acute inpatient residential treatment and prospective admission to an acute inpatient residential treatment program for treatment of his obsessive compulsive disorder. Findings:  The physician reviewer found that this patient presented to an acute inpatient residential treatment program with mild to moderate signs and symptoms of obsessive compulsive disorder.  He was recently enrolled in a 30-day dual-diagnosis rehabilitation program which he determined helped him with both binge drinking and obsessive compulsive symptoms. According to the mental status examination, he did not appear to be significantly depressed or anxious and denied psychotic processes. Significant stressors in this patients life included a conflicted relationship with his father.  He also had lost some levels of independence due to legal and other sequelae of his alcohol dependence. Admission to an acute inpatient residential treatment program during the time period at issue was not medically indicated. There was no suicidal ideation, and the patient was not demonstrating symptoms necessitating acute inpatient residential treatment level of care. Furthermore, his desire to accept recommended pharmacotherapy (antidepressant therapy) was refused immediately at admission. Additionally, the requested future acute inpatient residential treatment program is not medically indicated at this time.  This patient does not require the level of 24-hour supervision provided by an acute residential inpatient center. All told, the services at issue were not and are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female has requested Savella 50mg tablet, twice daily for treatment of her fibromyalgia.  Findings:  The physician reviewer found that Savella is FDA approved for the treatment of fibromyalgia and has been shown to be effective in clinical trials (Gendreau, et al). This specific medication was reported to have significant benefits in reducing fatigue in patients with fibromyalgia. This patients records demonstrate that she is currently taking Savella with substantial beneficial effects. Consistent with this support, the patient should not have to trial a formulary alternative that is not likely to offer the same relief of her symptoms as Savella.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy two times a week for six weeks. This patient has shoulder and right knee pain. She has been diagnosed with maltracking of the right patella and right patellar chondromalacia. Management of patellofemoral pain syndromes is challenging, with high rates of persistent symptoms despite extended follow up. The mainstays of management include quadriceps strengthening and stretching. There is no proven benefit of bracing. Surgical interventions in this clinical setting include measures to optimize patellar tracking including lateral retinacula lengthening or release. The patient in this case underwent right knee surgery that included lateral retinacular release and tricompartmental synovectomy. She has been undergoing physical therapy for a long time but her knee pain has persisted. There are no documented specific goals of the proposed additional physical therapy. She has functional range of motion and normal strength about the knee. The patient has been trained in a home exercise program and there are no impairments precluding transition to an independent program. Although she has persistent symptoms, there is no expectation that further physical therapy would improve the patients outcomes over an independent program. Therefore, the requested physical therapy two times a week for six weeks is not medically necessary for treatment of this patient.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 physical medicine and rehabilitation 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 32-year-old male enrollee requested the medication Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Based on the available data, the patient has minimal liver fibrosis.  There appears to be a component of fatty liver disease as well.  At this point, the patient is not likely to benefit from eradication of hepatitis C with only stage 1 fibrosis.  The standard of care would be to undergo yearly assessments of fibrosis by methods such as FibroSure.  All told, Harvoni is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for high-intensity focused ultrasound (HIFU). Based on current peer-reviewed medical literature, there is a paucity of data to support an indication for treatment with HIFU for this patients low risk prostate cancer. There are limited prospective randomized controlled studies comparing HIFU with other standard treatment approaches. Moreover, the current guidelines from the American Urological Association (AUA), American Society for Radiation Oncology (ASTRO), and Society of Urologic Oncology (SUO) do not recommend HIFU for the initial management of patients with prostate cancer. The U.S. Food and Drug Administration (FDA) has approved HIFU for the destruction of prostate tissue. However, HIFU has not received FDA approval for the treatment of prostate cancer. Given these findings, the requested HIFU is not medically necessary for treatment of this patient. 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 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 Miconazole/Monistat 7 cream, Percocet (acetaminophen and oxycodone) 10-325 #90, and stool softener 250 mg. Miconazole/Monistat 7 cream is not supported as medically necessary for treatment of this patient based on the available records. Monistat is effective for the treatment of acute vaginitis. The records available for review do not support that this patient has symptoms of candidal vaginitis. There is no documentation of a physical examination or laboratory test results consistent with candidal vaginitis. If the patient is having symptoms consistent with vaginitis, physical examination and laboratory testing are required to determine the appropriate treatment. Considering the available documentation, the requested Miconazole/Monistat 7 cream is not medically necessary. Regarding the continued use of Percocet, the documentation does not indicate that the patient has had a meaningful improvement in function while taking this medication. The Centers for Disease Control and Prevention (CDC) supports the use of opiate medications for non-cancer related pain when alternative therapies have not provided sufficient pain relief or are not tolerated, when there is documentation of functional improvement, and when the benefits of opioid therapy outweigh the potential harms. In this case, the patient has shown minimal improvement in function while taking this medication and she continues to have a depressed mood. Her medication regimen includes benzodiazepines, which increases the risk for adverse outcomes when taken concomitantly with opiate medications. Although the CURES reports have been consistent, the records do not include a recent urine toxicology screen. Given these findings, the continued use of Percocet (acetaminophen and oxycodone) 10-325 #90, is not medically necessary for treatment of this patient. In addition, the requested stool softener is not based on documentation of constipation or other bowel complaints. Although a stool softener may be indicated to treat constipation when taking opiate analgesic medications, there is no documentation that this patient has had any issues while taking Percocet or other medications in her regimen. Thus, the requested stool softener 250 mg is not medically necessary for this patient. Final Result: The reviewer determined that the requested medications 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 internal 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: Upheld

A 31-year-old male enrollee has requested the medication Actiq for the treatment of his back pain. Findings:  The physician reviewer found that although Actiq has only been approved by the FDA for cancer related pain, there are some clinical situations in which this medication can be appropriately used off-label for other forms of pain management. In the case of this patient, the submitted medical records do not outline in a prospective manner the failure of all the other forms of treatment tried and failed. Nor does the submitted evidence include objective medical record documentation which describes the benefit achieved from this off-label use of Actiq. In the case of chronic narcotic medication, such documentation should specifically include itemized functional improvements achieved by the patient from this medication in order to support its continued use. All told, the medical records provided contain insufficient documentation to support the medical necessity of Actiq, either retrospectively or prospectively.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee has requested a custom knee brace (L1846) for treatment of his knee, status post knee surgery. Findings:  The physician reviewer found that although functional knee braces are commonly prescribed after anterior cruciate reconstructive surgery, evidence for their effectiveness is lacking. No advantage has been found in their use as compared to the use of a neoprene sleeve, as noted by Birmingham and colleagues.  As noted by Smith and Davies, no significant difference has been identified between patients who wore postoperative braces and those who did not. A prospective, randomized, multicenter study did not identify any significant difference between braced and unbraced patients, as noted by McDevitt and colleagues. There is a lack of evidence regarding an effect on pain, motion, graft stability or protection from subsequent injury, per Wright and Fetzer. The custom knee brace (L1846) was not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic test or evaluation of the enrollees pregnancy. Findings:  The physician reviewer found that Per the American College of Obstetrics and Gynecology (ACOG), carrier screening is recommended before or during pregnancy for many autosomal recessive conditions even in the absence of family history. According to ACOG, Screening for spinal muscular atrophy should be offered to all women who are considering pregnancy or are currently pregnant. Moreover, ACOG also recommends cystic fibrosis carrier screening for all women who are considering pregnancy or are currently pregnant. While fragile X carrier screening is usually recommended for women with a family history of fragile X related disorders or intellectual disability suggestive of fragile X syndrome, ACOG states that a patient with no family history may request fragile X screening and it would be reasonable to offer screening after informed consent. Therefore, the genetic test was likely to have been more effective than the standard options available for the evaluation of this patient. Final Result: The 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: Physician reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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 33-year-old female enrollee has requested Nuvigil for treatment of her excessive daytime sleepiness due to multiple sclerosis related fatigue.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this clinical setting.  The medical evidence supports Nuvigil for the treatment of this patients condition.  This patient has relapsing-remitting multiple sclerosis, and she has had daytime sleepiness and fatigue.  There is evidence in the medical literature indicating that Provigil may be beneficial for the treatment of fatigue in conditions such as multiple sclerosis.  The alternative treatments, such as amphetamine, have greater side effects and abuse potential.  All told, Nuvigil is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested health and behavior intervention for the treatment of the enrollees Ehlers-Danlos syndrome. Findings:  The physician reviewer found that this patient has well-documented chronic pain that did not respond to standard therapies for pain. Based upon documentation submitted, the patients symptoms were significantly reduced during her stay. Meta-analysis reviewing behavioral therapy for chronic pain determined that it is a useful treatment in managing pain. Given the acute reduction of pain, health and behavior intervention was medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested authorization and coverage of the medication Nexium for the treatment of gastroesophageal reflux disease and Barretts esophagus.  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 overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bilateral knee osteoarthritis. A magnetic resonance imaging (MRI) of the left knee revealed severe osteoarthritis of the medial compartment. An MRI of the right knee revealed moderate osteoarthritis of the medial compartment. The patient reported knee pain, and physical examination findings included tenderness over bilateral knees. The patient has been treated with bilateral knee steroid injections, bilateral knee viscosupplementation injections, and oral and topical medications. The provider noted an x-ray of the knees obtained, revealed severe bilateral medial compartment osteoarthritis. The patient did not want to undergo bilateral knee replacement surgery. The provider noted Euflexxa injections administered and a Supartz injection administered provided 50% pain relief. The patient has requested authorization and coverage for Euflexxa injections to both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue is this case is whether Euflexxa injections to both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties which she does not want. Furthermore, there is a history of 50% pain relief from prior viscosupplementation injections. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections to both knees are medically necessary for the 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 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.