Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

The patient is an eight-year-old male diagnosed in April 2000 with autism. He has been receiving speech therapy since 2001. He continues to have significant speech delays. As documented by his therapist, the patients vocabulary is between 40-50 words. The patient and his therapist have also been working on who statements with some success. At issue is whether continued speech therapy is medically necessary for treatment of the patients medical condition. Upon review of the submitted therapy notes since September 2004, there has been some improvement primarily in vocabulary and receptive and expressive language skills. However, in reviewing the most recent progress reports dated March 2005 and May 2005 there is no documentation showing discrete functional goals. In addition, the March 2005 evaluation relies on testing performed three months earlier. Similarly, the May 2005 progress report relies on testing performed six months earlier. Thus, no standardized testing has been provided which documents improvement. Based upon the information provided, a well-defined treatment plan and goals have not been established for this patient. Furthermore, individualized speech therapy has not been well documented in the medical literature to significantly improve autism. As such, continued speech 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

A 26-year-old female enrollee has requested for hepatitis A vaccination.  Findings:  The physician reviewer found that the patient is not in a category for which vaccination for hepatitis A is recommended.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the UroLift procedure for treatment of enrollee's benign prostatic hyperplasia (BPH).  Findings:  Three physician reviewers found that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The study by Sonksen and colleagues compared prostatic urethral lift to transurethral resection of the prostate (TURP) in regard to lower urinary tract symptoms improvement, recovery, worsening of erectile and ejaculatory function, and continence. The study concluded that participants who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate as therapy for benign prostatic hyperplasia with regard to important aspects of quality of life. Moreover, the UroLift procedure is a well-established treatment for patients with benign prostatic hyperplasia. The UroLift procedure is a superior alternative to TURP as it can be performed as an outpatient with minimal bleeding and no need for a post-operative catheter with little risk of long-term incontinence.Final Result: All three reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physicians are board certified in urology and are actively practicing. The reviewer 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

A 52-year-old female enrollee has requested coverage for oxycodone liquid for treatment of the enrollees chronic pain syndrome, degenerative disc disease, and gastroesophageal reflux disease.  Findings:  The physician reviewer found that based on the records provided for review, the requested oxycodone liquid is medically necessary for this patients medical condition. The patient has a chronic pain condition due to degenerative joint disease of the spine. The patient also has severe digestive disease as documented by esophagogastroduodenoscopy and biopsy. The patient had multiple failed surgeries and tried several opioid medications without success. The patient displayed intolerance to oral medications as a result of her severe digestive disease. Liquid oxycodone at the current dose prescribed by her provider is an appropriate alternative to help reduce her chronic pain and maintain her functional status. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, injections and adjunctive medications to help reduce pain and improve the patients quality of life. Appropriately dosed opiates are considered adjunctive to this therapy with close monitoring by a certified physician (Fishman). In the medical literature, Staahl and colleagues performed a comparative study of oxycodone and morphine in a multi-model, tissue-differentiated experimental pain model. The authors concluded that a different pharmacological profile of oxycodone compared to that of morphine was shown, and noted that oxycodone may be a useful alternative to morphine in the treatment of visceral pain syndromes. Riley and colleagues performed a medical review to evaluate the efficacy of oxycodone in managing neuropathic and somatic pain, both malignant and non-malignant origin. The authors found that appropriately dosed oxycodone offers a fast onset of analgesia, controlling pain for hours and providing clinically meaningful relief of moderate to severe pain. In turn, the results included improved quality of life across a broad spectrum of pain types. The research indicated that oxycodone provides significant pain relief allowing relevant points of difference from other opioids and as such may be a suitable alternative to morphine. Therefore, the requested liquid oxycodone is supported as medically necessary for management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested a computed tomography angiography (CTA) for an evaluation of his coronary artery disease. Findings:  Two physician reviewers found that this patient had known coronary disease, including prior coronary stenting and presented with symptoms suspicious of recurrent coronary ischemia. In this circumstance, standard and established care in the medical community includes stress testing to both identify and quantify any coronary ischemia present. Coronary CTA only provides a rough assessment of coronary anatomy and does not evaluate the functional significance of any stenosis identified. In addition, artifacts from coronary calcium and stents during coronary CTA can sometimes preclude an accurate quantification of stenosis severity. According to a study by Miller and colleagues, CTA has been demonstrated to be less accurate compared to invasive coronary angiography and has the disadvantage of not being able to perform percutaneous revascularization during the same procedure, if clinically indicated. Current guidelines that are endorsed by several national organizations also do not definitively consider coronary CTA angiography appropriate in this patients particular clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 61-year-old female enrollee has requested reimbursement for Decision Dx Melanoma Gene Assay for evaluation of the enrollees melanoma.  Findings:  The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on Decision Dx Melanoma Gene Assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, Decision Dx Melanoma Gene Assay was not likely to have been more effective than other methods of evaluating this patient. Final Result: Two of three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 36-year-old female enrollee has requested a PET/CT scan for an evaluation of her primitive neuroectodermal tumor (PNET). Findings:  Two physician reviewers found that primary uterine PNET is extremely rare. It is clear from a review of the literature there is no accepted standard for staging and follow-up of this cancer. It is not known if primary uterine PNET behaves like the bone tumor members of the Ewing sarcoma family or if the same guidelines should be applied. As such, there is no preferred standard imaging for this condition. PET/CT was utilized previously for this patient and consistent assessment of her disease status would require that PET/CT be utilized again to assess her response to chemotherapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for conversion of gastric bypass revision surgery. In a comparison of revisional and primary bariatric surgery, Fulton and colleagues note that complications were significantly more frequent in revision patients than primary patients. Due to its risks, current medical literature does not support revisional bariatric surgery as the primary intervention to address weight regain after gastric bypass given the availability of less invasive, lower-risk endoscopic nonsurgical options for patients in this clinical setting. Dhindsa and colleagues note that transoral outlet reduction (TORe) is an endoscopic procedure that is safe and technically feasible for patients with weight gain post Roux-en-Y gastric bypass. Thompson and colleagues report that TORe is one approach to avoid weight regain. In this case, the patient has had weight regain following Roux-en-Y gastric bypass and has failed medications and other noninvasive measures to address weight regain. However, the records note that the patients provider does not recommend the patient as a candidate for surgical revision due to immediate risks. Given that surgical revision is significantly more invasive than endoscopic intervention, with a higher complication rate than primary bariatric surgery, the requested service is not medically indicated. Therefore, gastric bypass revision surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) in both knees. Findings:  The physician reviewer found that Functional limitations are noted in his ability to perform activities of daily living. He is status post bilateral knee arthroscopy with medial meniscus repair and chondroplasty of the medial femoral condyle. Physical examination findings have been consistent with radiographic evidence of bilateral knee medial joint space narrowing, small marginal osteophytes over the medial aspect of the medial tibial plateau, and bilateral flabella. The provider noted that the patient has failed to improve with conservative treatment including activity modification, physical therapy, exercise, and bracing. Bennett and colleagues recommend radiography as the initial imaging examination for nontraumatic knee pain. Per the American College of Radiology (ACR), an MRI examination for nontraumatic knee pain is indicated when the pain is persistent and conventional radiographs are nondiagnostic or when additional information is necessary before instituting treatment. MRI of the knee is an appropriate next step in the work-up of patients with chronic knee pain and initial knee radiographs demonstrating prior cartilage or meniscal repair. Evidence-based medical guidelines support MRI imaging in this patients medical condition to direct further treatment. For these reasons, the requested MRI in both knees is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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.
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 patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. According to the literature, 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. The breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 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: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested an MRI of both wrists/hands for the evaluation of her synovitis. Findings:  Three physician reviewers found that the use of MRI in patients with tenosynovial diseases is well-established and not at all experimental.  The evaluation of the flexor retinaculum for suspected carpal tunnel syndrome is well established.  In addition, since there is a question concerning the extensor tendons of the hand, an MRI would be the procedure of choice for imaging of such a structure.  The use of intravenous contrast will address the active synovial inflammatory nature of rheumatoid arthritis, and the MRI scan will also address the integrity of the flexor and extensor tendons of the hands and wrists.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested medication Sovaldi for treatment of his chronic hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  Per the medical records, this patient has no contraindications to interferon-based treatment and is motivated to begin therapy before his liver disease progresses.  Delaying treatment places the patient at risk and encourages progression of liver disease.  The current medical evidence supports Sovaldi in this clinical setting.  The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend daily Sovaldi, weight-based ribavirin and peginterferon as a treatment for interferon-eligible patients with hepatitis C genotype 1 infection.  All told, Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the patients decision to seek immediate medical attention was consistent with the actions of a prudent layperson. Upon review of the submitted medical records, the patient presented with severe pain and concerns that her pain was due to a problem with her spine and prior surgical repair. She was advised by her treating provider to go the ER. Aside from the pain, disruption or loosening of the vertebral hardware, spondylolishtesis of vertebrae, and synthetic discs could have caused a compressive neuropathy which may have caused distal muscle weakness, bladder and bowel dysfunction, and permanent disability.  There were also other possible etiologies of the back pain and headache including infection.  The ER visit was the appropriate venue for evaluation because of the level of evaluation required. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition that required immediate medical attention. Thus, the services meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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

The mother of a 16-month-old male enrollee requested authorization and coverage of a portable nebulizer for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested Zometa for treatment of her breast cancer.  Findings:  The physician reviewer found that in the adjuvant setting, not all bisphosphonates have been shown to be equivalent in efficacy. Therefore, the National Cancer Institute (NCI) includes Zometa as a therapeutic option in this clinical setting. All told, the use of Zometa is medically necessary and reasonable for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intravenous chelation services for treatment of the enrollees medical condition. Findings:  The 3 physician reviewers found that this patient has a history of multiple sclerosis which was documented as stable. The patient received multiple treatments of intravenous chelation for the treatment of toxic effect of unspecified metals which is documented as improved. Multiple sclerosis is most common immune-mediated inflammatory demyelinating disease of the central nervous system.  The current medical evidence does not support intravenous chelation services in this clinical setting. There is a lack of evidence to support chelation therapy over the disease-modifying agents. For patients with an acute multiple sclerosis exacerbation that results in neurologic symptoms and increased disability or neurologic deficits, high dose glucocorticoids is the recommended treatment. In this case, the patient is documented as being stable, without decline in function. There is no other medical condition documented that would benefit from chelation treatment.  All told, intravenous chelation services provided were not likely to have been of greater benefit than other treatment options.  Final Result: The 3 reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.