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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hormone pellet implantation. Findings:  The physician reviewer found that subcutaneous hormone replacement therapy (HRT) is considered a bioidentical hormone treatment. Bioidentical hormones are plant-derived hormones that are biochemically similar or identical to those produced by the ovary or body. The steroid hormones most commonly compounded include testosterone and estradiol. Studies evaluating subcutaneous HRT contain small subject numbers. For this reason, HRT is not adequately supported in the peer-reviewed medical literature. Further, subcutaneous HRT is not considered a first-line treatment in the selection of HRT, as it has not been demonstrated to provide a significantly increased benefit over oral HRT. Given the lack of evidence in randomized, peer-reviewed, published studies, the hormone pellet implantation provided in this case was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: All 3 reviewers determined that the service at issue was 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 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: Overturned

A 63-year-old female enrollee has requested a nuclear stress test, echocardiogram and Holter monitor for evaluation of her shortness of breath. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of a portion of the requested services.  This patient presented with unexplained dyspnea and palpitations, a normal cardiovascular physical examination, and no significant electrocardiographic changes.  In this clinical setting, further cardiac evaluation for either a dysrhythmia or coronary ischemia is medically indicated.  Current guidelines that are endorsed by several national organizations consider Holter monitoring reasonable and appropriate for evaluation of intermittent palpitations.  However, an echocardiogram is considered appropriate only if frequent ectopy, atrial fibrillation, supraventricular tachycardia or ventricular tachycardia is identified on Holter monitoring.  Echocardiography is not considered appropriate in the evaluation of infrequent atrial or ventricular ectopy without other evidence of heart disease. There are no accepted indications for echocardiography at this time. It is possible that the patients symptoms represent a coronary ischemic equivalent given her significant cardiac risk factors.  Further evaluation with stress testing is medically appropriate in this setting.  Current guidelines consider nuclear stress testing appropriate in patients with intermediate pretest coronary risk even with an interpretable electrocardiogram given the relatively low sensitivity and specificity of electrocardiographic changes during standard treadmill exercise electrocardiography.  Since this patient has an intermediate pretest probability of coronary disease based on her risk factors and she has symptoms suspicious of an ischemic equivalent, nuclear stress testing is medically indicated.  All told, the requested Holter monitor and nuclear stress test are medically necessary for the evaluation of this patient.  However, the medical necessity of the requested echocardiogram has not been demonstrated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old-male enrollee requested authorization and coverage of continued chiropractic care. The Health Plan denied the request indicating that continued chiropractic care is not medically necessary for treatment of the enrollees neck pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer upheld the Health Plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Genotropin for treatment of the enrollees growth hormone (GH) deficiency.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patient meets criteria for GH deficiency, and GH therapy is clinically indicated. However, a change specifically to the brand Genotropin is not medically necessary. Rather, the vehicle of administration of the GH should be changed to improve adherence to therapy and allow for accurate administration of the prescribed dose. The Health Plans preferred formulary brands of Saizen and Humatrope are both appropriate and reasonable in this clinical setting and the patients parents can be taught how to administer either Humatrope of Saizen via syringe and vial, which will bypass the technical difficulties that ensued with use of the Easy Pod device. Based on the medical literature cited above and the documentation submitted for review, the request for Genotropin is not medically necessary for treatment of the patients medical condition. 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 pediatric endocrinology 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 patient is a 2-year 11-month-old female with a history of global developmental delay including a delay in ambulation until age 2. She has a history of recurrent otitis media with effusion and underwent bilateral tympanostomy and adenoidectomy at age 19 months. She has a history of esotropia. An MRI of the brain was within normal limits but according to the neurologist the patient showed delays in personal, social fine motor, and gross motor skills. At issue is whether continued speech therapy is medically necessary.Review of the relevant medical literature reveals no connection between hearing, speech loss and global developmental delay. It is certainly possible that the patient had hearing losses, but such losses were never documented before or after the tympanostomy and adenoidectomies. It is more probable that the speech loss is associated with the patients developmental delay. Speech therapy for the treatment of such a delay is educational rather than medical in nature. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dilaudid, Physical Therapy Sessions for lower back pain, and a Saunders cervical traction device.The submitted documentation does not support that the requested medication, physical therapy services, and device are medically necessary.Regarding the patients request for Dilaudid, there is no documentation supporting the medical necessity for this medication. The submitted documentation indicates that the patient did not return for two scheduled follow-up pain management appointments. The patients records do not establish that he has moderate to severe pain after having failed first-line non-opioid analgesics. There is no clear documentation that the patient has attempted medication management of his chronic pain with antiepileptic drugs (AEDs), antidepressants, or prescription NSAIDs. Under these circumstances, there is insufficient support for the use of short-acting opioids at this time. Therefore, the requested Dilaudid is not medically necessary for this patients medical condition.Regarding the patients request for physical therapy for the lower back, the medical records do not establish that the requested services are medically necessary. The submitted documentation indicates that the patient did not return for two scheduled follow-up pain management appointments. There is also no documentation of objective exam findings that would support the need for the skills and knowledge of a physical therapist over exercises to be performed within the context of a home exercise program. Accordingly, the requested 12 (twelve) Physical Therapy Sessions for lower back pain are not medically necessary for this patients medical condition.Regarding the patients request for a Saunders cervical traction device, the medical records do not establish that the requested device is medically necessary. The submitted documentation indicates that the patient did not return for two scheduled follow-up pain management appointments. There is also no documentation with objective exam findings that would support use of the requested device over that of ongoing active exercises. The combined medical records also do not document a provider recommendation for this device. Under these circumstances, the requested Saunders cervical traction device is not medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication, physical therapy services, and device are not medically necessary for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old male enrollee has requested for Qualaquin 324mg capsules for treatment of his nocturnal leg cramps. Findings:  The physician reviewer found that the FDA has noted that this medication should not be used for prevention or treatment of leg cramps, as there is considerable risk associated with the medication. Qualaquin use can cause abnormal heart rhythms, cinchonism, and death (perhaps due to pulmonary edema).
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested inpatient hospitalization for treatment of his bipolar II disorder.  Findings:  The physician reviewer found that the progress notes reflect a subjective report of depression in the absence of acute psychotic features, and the absence of acute suicidal ideation with plan.  The patient was reportedly compliant with medication and treatment and was able to take care of his personal needs.  In general, patients should be treated in the least restrictive setting that is most likely to prove safe and effective. The acute course of electroconvulsive therapy typically consists of six to 12 treatments, and generally does not exceed 20 treatments.  Electroconvulsive therapy is increasingly being provided in an outpatient setting.  This patients progress notes do not show evidence of psychiatric or medical acuity requiring inpatient hospitalization during the dates of service at issue.  Continued electroconvulsive therapy could have been provided in an outpatient setting.  The documentation does not indicate that the patient would have deteriorated in functioning if transitioned to a lower level of care as of the said date.  All told, the medical necessity of inpatient hospitalization at Sutter Center for Psychiatry provided during the said timeframe has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested inpatient hospital services for treatment of his angina.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this circumstance of unstable angina despite optimal medical therapy, it is reasonable to expect that on presentation with chest pain that a hospital admission would be medically necessary.  Specifically, it would not be expected that observational level of care would be sufficient and it would not be expected for the patients hospital length of stay to be less that one day or spanning less than two midnights.  Patients with unstable angina usually require intravenous therapy that is not able to be safely provided at an observational level of care as well as advanced procedures that require hospital admission.  The current medical evidence supports the services at issue in this clinical setting.  All told, inpatient hospital services provided were medically indicated for the treatment of this patient.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 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

The parent of an 11-year-old female enrollee has for magnetic resonance imaging (MRI) of the brain for evaluation of the enrollees pineal cyst. Findings:  The physician reviewer found that migraines in children are rarer than in adults. When a child develops persistent headaches, it is imperative that severe etiologies be ruled out. Given that this patient has a documented pineal cyst, serial imaging studies are warranted to rule out pineoblastoma or apoplexy. Either of these scenarios would significantly change the patients medical management. Additionally, after an extended period of unexplained headaches, MRI may help to identify a cause unrelated to the patients pineal cyst.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that guidelines for the evaluation and management of dyslipidemia and cardiac risk do not recommend routine screening with specialized testing included the genetic tests in dispute (Greenland, et al; Stone, et al). Treatment change based on the results of these specialized tests has not been shown to improve cardiac outcomes incremental to that achievable using standard clinical risk profiles combined with basic lipid analysis. In sum, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 parents of a sixteen year-old male who was suicidal ideation concurrent with a worsening of depression are requesting reimbursement for the acute inpatient psychiatric treatment services.  Reviewers Findings:  The reviewing physician found that the entire course of the patients stay was necessary.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing (methylenetetrahydrofolate reductase mutation (MTHFR) testing).  Findings:  Three physician reviewers found that per the medical evidence, there is only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. There is a lack of large randomized trials supporting its use. The existing studies have also indicated that there is no significant correlation between either genotypes or medication serum concentration and response to treatment. The current evidence does not support the use of genotyping when choosing an antidepressant. Therefore, MTHFR testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 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 reviewers 1, 2 and 3 are board certified in psychiatry 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: The patient has requested authorization and coverage for Synvisc-One injections for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior viscosupplementation. Given the patients limited options and based on the current medical literature, the requested services are medically indicated.  Therefore,  Synvisc-One injections for 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.
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:  Two physician reviewers found that the American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages this technique brings to radiologists interpreting screening exams especially in cases of dense breast tissue.  These advantages have resulted in a decrease in callbacks and increase in detection of small cancers.  Thus, tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  However, since an abnormality was detected on the screening exam which included tomosynthesis it was not reasonable to repeat that portion of the diagnostic exam.  Since calcifications were questioned and were the reason for the diagnostic study at issue, conventional magnification views would have been sufficient to make a recommendation. Final Result: The reviewers determined that a portion of services 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 partially 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

A 52-year-old female enrollee has requested Effient, 5mg per day for treatment of her status post myocardial infarction.  Findings:  The physician reviewer found that current expert consensus guidelines do not recommend Effient as a first-line agent after drug eluting stent placement.  Available recent data indicates a significantly higher bleeding risk with this medication compared to Plavix. Therefore, Effient is usually considered as an alternative therapy to Plavix only if there is a contraindication to Plavix, such as an intolerance or allergy, if there is failure of an adequate trial of Plavix, or if there is an unusually high-risk thrombotic situation in which it can be reasonably expected that the combination of aspirin and Plavix would not be sufficient to prevent thrombosis from recurring.  None of these conditions were documented in the medical records in this case.   All told, Effient, 5mg per day, is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested dual therapy Sovaldi tablets and RibaPak tablets for treatment of his chronic hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  The submitted medical records do not support that the patient is interferon-ineligible as defined by the American Association for the Study of Liver Diseases and the Infectious Disease Society of America.  The lack of interferon-ineligibility broadens the treatment options available to this patient per the current guidelines.  Further, the American Association for the Study of Liver Diseases and the Infectious Disease Society of America recommend delaying treatment for some patients in this clinical setting, as waiting for future highly effective, pan-genotypic, direct acting antiviral combinations in interferon-free regimens may offer potential advantages.  All told, the requested dual therapy Sovaldi tablets and RibaPak tablets are not medically indicated for the treatment of this patient.