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

Nature of Statutory Criteria/Case Summary: An enrollee has transcatheter embolization of pelvic veins for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that chronic pelvic pain is a very complex problem and is poorly understood.  It is typically very difficult to treat as the disease process is multifactorial without one specific etiology, and clinically can present in different ways and can change over time.  A specific diagnosis is not found in the majority of cases. Some common diagnoses include endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis.  In this patients case, the clinical presentation is strongly suggestive of pelvis congestion.  Other pelvic pathology has been ruled out. The medical evidence supports the requested services in this clinical setting.  She has failed medical management and comparisons of the surgical management options specific to her medical situation indicate she would be a better candidate for occlusion therapy.  In sum, the requested transcatheter embolization of pelvic veins is likely to be more effective than other treatment options.Final Result: Two 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: All three physician reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewers are 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: An enrollee has requested authorization and coverage for a three-wheeled mobility scooter and trunk lift. Findings:  The physician reviewer found that the submitted records do not support that the requested durable medical equipment is medically necessary at this time. The records indicate that the patient has multiple chronic medical conditions, but her primary mobility-related issue is back pain with intolerance of long periods of standing and ambulating for long distances. Otherwise, the patient is neurologically intact. The records do not establish that the patient has impairments that would preclude the use of a cane or walker to accomplish her mobility-related activities of daily living. The submitted documentation does not include objective findings such as examination notes describing gait, mobility deficiencies, or medication management due to pain. In addition, the records indicate that the patient has health conditions such as obesity and hypertension that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device would encourage. Under these circumstances, the requested three-wheeled mobility scooter and trunk lift are not medically necessary for the patients medical condition at this time.Final Result: The reviewer determined that the requested durable medical equipment 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for colchicine 0.6 mg oral capsule, one capsule twice daily for treatment of the enrollees familial Mediterranean fever. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The drug colchicine is U.S. Food and Drug Administration (FDA) approved for the use in treatment of gouty flares and familial Mediterranean fever.  For the treatment of a gouty flare, a medication from the nonsteroidal anti-inflammatory drug (NSAID) class is considered first-line treatment.  If a patient cannot tolerate treatment with an NSAID or has a contraindication to use of these medications, then colchicine is recommended.  Familial Mediterranean fever is a hereditary auto-inflammatory disorder characterized by recurrent bouts of fever and serosal inflammation.  Colchicine is recommended to prevent acute attacks and minimize subclinical inflammation in between attacks, and to prevent the development and progression of amyloidosis for patients with familial Mediterranean fever.  In this case, the documentation submitted by the provider does not support a diagnosis of gout or familial Mediterranean fever.  Given the lack of medical records documenting that the patient has familial Mediterranean fever, the medical necessity for the continued use of colchicine is not established.  Thus, colchicine 0.6 mg oral capsule, one capsule twice daily is not medically indicated for the treatment of this patient. 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 physician 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 has requested Remicade 15 mg/kg for treatment of Crohns disease. Findings:  The physician reviewer found that the Food and Drug Administration's (FDA) recommended dosage of Remicade for the treatment of patients with Crohns disease is 10 mg/kg every 8 weeks. The medical literature does not support the use of an increased dosage although it reports that some patients may become resistant to therapies justifying its off-label use. However, this patient has not been treated with alternative therapies such as Humira and Cimzia. Moreover, this patients documentation suggests that she is resistant to the effects of Remicade, likely due to the development of pre-formed antibodies. Thus, she would not be considered a candidate for treatment with Remicade at a dose higher than approved by the FDA and supported in the available scientific data. For these reasons, the requested dosage of Remicade is not clinically indicated for management of this patients Crohns disease.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested for an additional two months of intensive stroke rehabilitation day treatment for treatment of his impairments related to a right middle cerebral artery dissection. Findings:  The physician reviewer found that no evidence exists that the long-term outcome for this patient will be altered by continuing therapy at the present intensity versus at a lower intensity. Therapy should be continued, but can be provided at a lower level of care. It should be discontinued when there is no continuation of gains relevant to functional status.
Appeal type: Experimental/Investigational
Decision: Upheld

A 21-year-old male has requested artificial disc replacement at L4-5 and fusion at L5-S1 for treatment of his pars defects at L5, anterolisthesis of L5 and S1, and disc protrusion at L4-5 with foraminal narrowing.   Findings:  Three physician reviewers found that he has a history of low back pain. He has been treated with medications, chiropractic care, and injection therapy. None of the treatment has provided any lasting relief. His neurological examination has not shown any motor, sensory, or reflex deficits. Magnetic resonance imaging (MRI) has consistently shown a congenitally narrow spinal canal, facet and flavum hypertrophy at L3-4 with a disc bulge. The patient also has disc desiccation at L4-5. The patients provider has recommended artificial disc replacement (ADR) at L4-5 and instrumented fusion L5-S1. The patients request for authorization and coverage for these procedures has been denied by the Health Plan as experimental and investigational. This young patient has chronic low back pain. He has an abnormal back x-ray and lumbar MRI. The MRI has improved from the previous study, no longer showing the edema in the L5 segment. He has degenerative changes and disc bulges at both L3-4 and L4-5. There is inadequate evidence that the L4-5 segment is a pain generator and requires ADR or fusion. To consider ADR at L4-5 in this patient is contrary to FDA approval, since it would be performed in conjunction with a fusion at L5-S1. This is not an approved use of this device. Use of ProDisc-L has been approved by the FDA. However, the FDA has required 5-, 7- and 10-year post-approval studies to determine its long-term safety and effectiveness. These studies are ongoing and have not been completed or reported. In the absence of adequate large, scientific, long-term studies that have confirmed long-term safety and effectiveness of this device, artificial disc replacement remains unproven (Zigler, et al).
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female with arthrofibrosis of the knee who is requesting reimbursement for physical therapy she received from January 2006 through February 2006. The Health Plan has denied the patients request on the basis that the physical therapy at issue was not medically necessary.Discharge to a home exercise program would have been an appropriate as of January 2006. Skilled physical therapy intervention was not medically warranted as of that date based upon the information provided. Range of motion exercises could have been self-taught via a HEP sheet. There is no evidence demonstrating that the patient warranted the level of care provided by a skilled therapist during the period in question. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested for an MRI-guided focused ultrasound ablation for treatment of her uterine fibroids. Findings:  Three physician reviewers found that focused ultrasound has been reported for the treatment of multiple medical diagnoses including liver, prostate and breast neoplasms. Ultrasound waves are guided by means of an MRI scanner, travel through the abdominal wall and converge at the site of the lesion. Thermoablation occurs only at the site of the convergence. Temperature feedback is achieved continuously during the therapy. The FDA approved the use of this modality in the treatment of uterine fibroids following the completion of a multicenter trial, published in January, 2006. This is the only known published trial with a follow-up of clinical outcomes. 176 women were entered, and 109 treated, indicating a large exclusion. Uterine volumes, symptom severity scores and quality of life scores were performed. A mean of slightly greater than one fibroid was treated per subject. Given the strict limits on the size of the ablation, less than 10% of the uterine volumes were treated. The authors concluded that the treatment held promise for a noninvasive method of fibroid treatment, but cautioned that a randomized clinical trial was necessary to confirm whether this is an effective treatment options for fibroids. The efficacy and safety of the proposed treatment has been placed into serious question by peer review. Although the study was well done in its limited context, it is curious the FDA would approve this modality given the small patient numbers reported, the short follow-up and poor shrinkage response of the lesions. The authors themselves admit the significant limitation of the study and that more and larger studies are required to alleviate these concerns and to adequately establish this treatment as within the standard of care. In addition, there are still no adequate peer-reviewed studies directly comparing the safety and efficacy of MRI-guided focused ultrasound ablation with standard interventions.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her exam been done using two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 70-year-old male enrollee has requested for Elidel 1% cream for treatment of his psoriasis. Findings:  The physician reviewer found that the first-line therapy for treatment of psoriasis in these areas is considered to be low potency topical steroids, which are available as both creams and ointments, as noted by Kalb and colleagues. Short courses of topical steroids with appropriate breaks from steroid therapy is a reasonable approach for both flares and long-standing disease.  The consensus report from Kalb and colleagues also indicates that the effectiveness of topical immunomodulators (Elidel or Protopic) is not as great as results seen with topical steroids.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of Kyphoplasty Surgery for the treatment of Systemic Lupus Erthematosus (SLE).  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 upheld the health plans denial on the basis that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested naturopathic consultation and therapy for treatment of her gastrointestinal symptoms.  Findings:  The physician reviewer found that the patients symptoms are consistent with IBS and it does not appear that all of the commonly prescribed therapies for this condition have been exhausted. There is no scientific evidence supporting a naturopathic approach in the treatment of IBS and it is not consistent with the standard of care nor recognized as being potentially beneficial within the gastrointestinal community.
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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female has requested coverage for past and continued chemical dependency residential treatment center (RTC) level of care services for treatment of her opioid addiction.   Findings:  The physician reviewer found that in general, modern psychiatric practice aims to provide care at the least restrictive setting that is likely to effectively address the issues driving the symptom complex or pathological behaviors which cause functional impairment. Physicians and health care providers rely on clinical judgment in the context practice guidelines, peer reviewed literature and placement criteria to assist with level of care determination process. Regarding residential treatment placement for patients with substance use disorders, the American Psychiatric Association (APA) recommends residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. In this particular case, the patients drug use dominates social and family dynamics and precludes vocational pursuits. Further, she poses an imminent risk to relapse upon discharge in her current state as she lacks a harmonious living environment and sober social supports to facilitate recovery. These factors represent Dimensions 5 and 6 of the American Society of Addiction Medicine (ASAM), which in turn support placement at the residential level of care. Moreover, the patient failed a less restrictive treatment setting prior to the disputed service as she was using during her intensive outpatient services. Consistent with the current practice guidelines and peer-reviewed literature, residential placement is safe, appropriate and consistent with good medical practice for this patient at this time. In sum, the chemical dependency residential treatment center services were and are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 61-year-old male with refractory daily migraine or tension headaches.  His diagnostic workup included lumbar puncture with measurement of opening pressures, but the source of his headaches has not been identified. The patient has tried acupuncture, Botox, and an exhaustive list of preventive and abortive medications. A treatment trial of Lyrica was prescribed by his neurologist. The Health Plan has denied authorization for the medication as not medically necessary for treatment of migraine headaches.The patients headaches are unquestionably refractory to standard treatments as numerous preventive medications have been tried and failed.  The safety of Lyrica has been sufficiently tested in other clinical applications. Lyrica should be approved on an interim basis. The patient should be titrated up to either therapeutic success or failure monitoring for side effects over a one to two month span.  He should then be reassessed, with a review of his headache diary as well as desirability measures such as drowsiness or dizziness.  If treatment with Lyrica is beneficial authorization should be continued.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old male who was seen and evaluated by his primary care physician and referred to a dermatologist for his psoriasis. The patients physician noted the patient wanted to see a dermatologist regarding a cyst of his back. The cyst is not described. The patient was referred to a dermatologist who noted the patients complaint about the cyst of the back, which are not described but diagnosed as epidermal inclusion cysts. Surgical excision of the cyst has been recommended. The Health Plan indicates the patients medical records do not demonstrate surgical excision is medically necessary.The Health Plans denial should be upheld. The submitted medical records mention the cyst of the back in several places but do not describe the size of the cyst or medical indications for the proposed removal. As such, there is no evidence the requested procedure is medically warranted. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.