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

The patient is a 10-year-old female with attention deficit hyperactive disorder (ADHD) and developmental delay. She has been treated with Adderall and Strattera. Based on the submitted information, it does not appear the patient has been tried on amphetamines or methylphenidates. The patients mother has requested authorization and coverage for Strattera. The Health Plan has denied the request on the basis that Strattera is not medically necessary for treatment of the patients ADHD.Review of the submitted clinical information demonstrates conventional therapy has not been attempted. There is no evidence the patient has undergone a trial of amphetamines or methylphenidates. Absent a trial of these medications, there is no medical indication for use of Strattera. Furthermore, Strattera in combination with Adderall is not recommended. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested colonoscopy is not medically necessary for evaluation of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested colonoscopy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee requested the drug combination Sovaldi, Ribavirin and peginterferon for medical treatment of the her hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested drug combination in this patients case.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA).  Based on the medical records, this patient has no contraindication to interferon-based treatment and is motivated to begin therapy now out of concern that her liver disease may otherwise progress.  Delaying treatment may encourage progression of liver disease and compromise treatment efficacy.  Therefore, the requested drug combination Sovaldi, ribavirin and peginterferon is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested insertion of a lumbar artificial intervertebral disc for the treatment of the enrollees medical condition. Findings: The physician reviewer found that the requested insertion of a lumbar artificial intervertebral disc at L5-S1 has not been established as medically necessary for treatment of this patients medical condition. There are currently inadequate data in the peer-reviewed literature to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential side effects that may occur with longer follow-up have not been fully documented. Zigler and colleagues completes a randomized, prospective, multicenter study of ProDisc-L versus circumferential fusion for low back pain. This study identified a reasonable cohort, subscribed the sample in a short time period, and demonstrated minimal attrition. However, the study lacks sufficient detail for independent evaluation of the data to confirm or reject the authors conclusions. In this case, imaging showed degenerative changes at L5-S1, but the patient has scoliosis above this level. There is no indication for surgery in this clinical setting and the patient is unlikely to benefit in the long-term. Given the lack of evidence in the peer-reviewed literature supporting insertion of a lumbar artificial intervertebral disc at L5-S1, the requested services are not medically necessary for treatment of the patients medical condition.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 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 55-year-old female enrollee requested a neurocognitive rehabilitation treatment program for medical treatment of her cognitive disorder secondary to concussion injury.   Findings:  The physician reviewer found that in the largest meta-analysis on the efficacy of cognitive rehabilitation in this clinical setting, there has not been any defined benefit with cognitive rehabilitation. Chung and colleagues reported that they identified insufficient high-quality evidence to reach any generalised conclusions about the effect of cognitive rehabilitation on executive function, or other secondary outcome measures. The authors also recommended that further research is needed comparing cognitive rehabilitation with no intervention or sensorimotor interventions. Accordingly, the requested neurocognitive rehabilitation treatment program is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male has requested physical therapy for treatment of his delayed developmental milestones, visual impairment, autism and cerebral palsy.  Findings:  The physician reviewer found that cerebral palsy is a non-progressive encephalopathy that occurs early in life, and results in numerous neurologic, motor, and postural deficits in the developing child. Children with cerebral palsy frequently have seizures, as well as speech and language delays, visual impairments, and cognitive delays. Secondary deficits in sensory and psychosocial skills may also result. Early intervention using a team approach optimizes each childs potential for development and prevention of secondary deficits. Members of the team typically include a pediatrician, neurologist, occupational therapist, physical therapist, and speech and language pathologist.  Physical therapy is a mainstay of treatment for cerebral palsy. Its focus on function and movement maximizes a childs potential for independence and mobility.  This patient has cerebral palsy, visual impairment, and autism. He has shown progress with physical therapy up to this point, particularly with gait. However, he continues to have significant challenges that impact his functional mobility, and these challenges can be successfully addressed with physical therapy interventions. All told, the requested physical therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old male enrollee has requested Lipoprotein-associated phospholipase A2 (LP-PLA2) and homocysteine laboratory testing for evaluation of his cardiovascular issues. Findings:  Three physician reviewers found that the current guidelines do not recommend routine use of advanced lipoprotein tests primarily because it is unknown if any incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. A consensus statement endorsed by the American Diabetes Association and the American College of Cardiology Foundation advocate measuring atherogenic particle concentration either as apolipoprotein B (apoB) or LDL particle concentration in patients at high risk for cardiometabolic disorders. At this time, non-HDL cholesterol or the total/HDL cholesterol ratio is of comparable predictive strength and supported in the scientific studies for use in patients at low risk for coronary artery disease (CAD), as in this patients case. Thus although the LP-PLA2 may provide valuable information in patients at moderate to high risk for CAD, this patient cannot be regarded as having moderate to high risk. Therefore, the diagnostic testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested Forteo for treatment of her osteoporosis.   Findings:  The physician reviewer found that while the patient does have osteoporosis, she has not been tried on a bisphosphonate. Her previous tibial fracture was a traumatic fracture, not a fragility fracture. Forteo is generally not a first-line treatment. It is typically reserved for (1) patients with severe osteoporosis as measured by a T-score of -3.5 or below without fracture or -2.5 or below with a fragility fracture; (2) patients who not able to tolerate bisphosphonates or have relative contraindications to this therapy; or (3) patients who fail other osteoporosis therapies as indicated by fracture and loss of bone mineral density (BMD) in spite of compliance.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with a BMI of 48 who is requesting a long-limb Roux-en-Y procedure for her obesity. She has comorbid conditions of hypertension and diabetes. The Health Plan has authorized standard Roux-en-Y gastric bypass.Long-limb Roux-en-Y has been shown to have greater complications and less success than other bariatric procedures and has not been established as more beneficial than other procedures. The Health Plan is offering the patient appropriate and indicated services. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series in the right knee at this time, and an Orthovisc injection series in the right knee in six months.Findings: Current medical literature pertaining to viscosupplemention reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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, there is a history of viscosupplementation with Orthovisc series every 6 months for 10 years with known benefit including pain relief, and functional improvement with regard to clicking and grinding. Accordingly, the requested Orthovisc injection series in the right knee is medically necessary for the patient's medical condition. Furthermore, the requested Orthovisc injection series in the right knee in six months is also medically necessary for the patient's medical condition.Final Result: The reviewer determined that the requested services are medically necessary for this 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: Medical Necessity
Decision: Overturned

A 66-year-old male enrollee has requested the prescription medication Celebrex for the treatment of his osteoarthritis of the lumbar spine. Findings:  The physician reviewer found that the Health Plans denial of  authorization for Celebrex for the treatment of the patients degenerative joint disease of the lumbar spine is not correct given his history of ITP. Immune ITP is a recognized, though rare, complication arising from the use of naproxen and certain other NSAIDs. The patient has successfully used Celebrex for several years and has not had platelet problems. He has an osteoarthritic condition and it is not reasonable to require a trial of four NSAIDs in this instance
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested acupuncture for treatment of her multiple myeloma.  Findings:  The physician reviewer found that this patient underwent acupuncture sessions for the treatment of fatigue, neuropathy, and low energy which are side effects from the chemotherapy used for the treatment of her multiple myeloma. The patient reported that she experienced improvement in her sleep and ability to relax, but there are no objective, significant benefits documented. In addition, no pre-care baseline was recorded in order to assess the benefits of an acupuncture trial. In addition, no measurable, objective symptoms, functional deficits, or improvement was noted by the provider in order to support an indication for acupuncture. Further, the peer-reviewed medical literature on the use of acupuncture for the treatment of the secondary effects of chemotherapy in patients with multiple myeloma is limited. Based on the records reviewed, the requested acupuncture care is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR surgical transperineal placement of biodegradable material (CPT 55874). Specific concerns during prostate radiation include rectal toxicity due to exposure of the adjacent rectum to radiation. One mechanism of dealing with this issue is to create a space between the prostate and rectum, so that the rectum is out of the radiation treatment field and receives less radiation. A phase 3 study has been performed which examined the SpaceOAR system (Karsh, et al.). The authors reported that the patients who underwent treatment with the perirectal spacers had reduced rectal radiation and toxicity, with decreased rates of decline in bowel quality of life. The National Comprehensive Cancer Network (NCCN) now endorses the use of perirectal spacers for use during radiation therapy for prostate cancer. The NCCN noted that perirectal spacers can be utilized to improve sparing of the adjacent rectum. Based on the results of the positive phase 3 study and the endorsement by the NCCN, the requested SpaceOAR surgical transperineal placement of biodegradable material (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested SpaceOAR surgical transperineal placement of biodegradable material (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2, and 3 are board certified in radiation oncology 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: A enrollee has requested authorization and coverage for a consultation with a clinical geneticist. Findings:  The physician reviewer found that the records indicate that this patient has a mitochondrial disorder due to a mutation in mitochondrial DNA (m.3242A>G). This particular mutation and the spectrum of disease associated with it is reasonably well characterized. This mutation is associated with mitochondrial encephalopathy, lactic acidemia and stroke-like episodes (MELAS). Some patients present with a MELAS phenotype and others present with diabetes and hearing loss, and there is a spectrum of disease, depending in part on the mutation burden and tissue distribution of the mutation. Thus, referral to a clinical geneticist with expertise in mitochondrial diseases is indicated for diagnostic purposes. All told, the requested consultation with a clinical geneticist is medically necessary for evaluation of this patients medical condition. 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 clinical genetics 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 digital breast tomosynthesis for evaluation of her left bloody nipple discharge.  Two physician reviewers found that while there is a lack of long-term studies showing increased survival rates when mammography is supplemented with digital breast tomosynthesis, the technique has gained significant popularity due to improved detection of small cancers particularly in dense or heterogeneously dense breast tissue. For this reason, the addition of digital breast tomosynthesis to the typical four view screening digital mammographic study is more beneficial in well selected patients than digital screening mammography alone. As this patient presented with bloody nipple discharge, the use of digital breast tomosynthesis in addition to standard mammography was likely to have been more beneficial than any available technique. Final Result: Two reviewers determined that the services at issue were medically necessary for evaluation of the patients medical condition. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the continued psychiatric residential treatment center (RTC) services rendered for treatment of the enrollees behavioral health issues.Findings: The physician reviewer found that the patients medical records indicate the patient had been in prior treatment modalities of different levels of care. Progress notes directly prior to the patients RTC admission indicate that the treatment team believed the patient was in need of RTC level of care due to her risk of self-harm and suicide. The patient has had numerous relational problems with her family and was given a parent-child relational diagnosis. During the initial portion of the patients stay she expressed somatic complaints and complained about taking psychotropic medication. She did not have any self-harm behaviors or aggression towards any other peers. However, she was minimally invested in her treatment and further outpatient treatment would not likely have engaged her appropriately. As her stay progressed, she became more invested in her treatment and was noted to be insightful into her own problems as well as the problems of her peers. Thus, the initial portion of her stay was medically necessary due to her numerous treatment failures at lower levels of care and the recommendation from the inpatient treatment team. However, after her initial stabilization period, she could have then been treated in a less restrictive setting due to the fact that she was not engaging in any dangerous behaviors, was cooperative in treatment, and had gained insight into the benefit of continued need for treatment. Moreover, the progress notes do not reflect that intensive family therapy was occurring while the patient was in the RTC, which was a source of the patients functional problems. Intensive family therapy could have occurred in a less restrictive treatment setting. In addition, the patient could have received DBT in a less restrictive setting (Mehlum, et al). For these reasons, the continued psychiatric RTC services rendered were medically necessary for treatment of this patients behavioral health condition, and the services were not medically necessary. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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.