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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Smart Pill Motility Testing System (CPT 91112).Findings:  The physician reviewer found that Treatment of constipation revolves around adequate water and fiber intake. Medical therapy involves use of fiber buking agents, osmotic laxatives and other agents for refractory constipation. Typically, constipation can be caused by slow transit or defecatory dysfunction caused by dyssnergic defecation. Dyssnergic defection can be evaluated using anorectal manometry testing. Colonic transit abnormalities can be evaluated by use of radiographic studies such as Sitz marker studies and SmartPill wireless motility capsule. In this case, the patient presents with chronic symptoms of abdominal pain, nausea, gas-bloat and constipation. There are no randomized controlled trials that have proven that the SmartPill capsule is safer and more effective and further improves health outcomes compared to conventional methods such as the Sitz marker study. Accordingly, the requested Smart Pill Motility Testing System (CPT 91112) is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in gastroenterology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Findings: Two out of three physician reviewers found that the requested Smart Pill Motility Testing System (CPT 91112) is not likely to be more beneficial than any other available standard treatments for the patients medical condition
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain for an evaluation of her dizziness. Findings:  The physician reviewer found that this patient reported symptoms of dizziness and light-headedness (possibly positional). The differential diagnosis of dizziness is wide, including vertigo, presyncope, seizure, anxiety, stroke, anemia, and residual effect of head trauma. Appropriate evaluation would include a detailed history, measurement of vital signs, otologic examination, cardiac physical exam, neurologic exam, and consideration of provocative testing such as the Hallpike maneuver and forced hyperventilation. As a result of clinical assessments, further diagnostic testing may at times be indicated, including blood tests, EKG, EEG, and brain imaging. Isolated dizziness is unlikely to represent serious structural disease such as transient ischemic attack or brain tumor and as such, MRI and MRA are not helpful. Based upon the evidence provided, there were no signs or symptoms that would support the medical necessity of the MRI and MRA tests performed in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 27-year-old male enrollee has requested chemosensitivity testing for the treatment of his recurrent testicular cancer. Findings:  Three physician reviewers found that there is limited data addressing the utility of in-vitro chemosensitivity testing in predicting clinical response to chemotherapy. The available data does not suggest selecting therapy based upon in-vitro testing is superior to selecting chemotherapy based upon known response rates. Neither the American Society of Clinical Oncology nor National Comprehensive Cancer Network guidelines support the use of chemosensitivity testing at this time.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni for 12 weeks for medical treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. These new guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Moreover, interferon-based regimens are no longer recommended for first-line therapy. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni for 12 weeks should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested stem cell treatments for treatment of his medical condition. Findings:  Three physician reviewers found that stem cell therapy for the treatment of cerebral palsy is in its theoretical infancy with a lack of adequate clinical trials. The type of cells, method of introduction, and dosing is not yet clear. At this time, there is a lack of general agreement about the type of stem cells to be used such as mesenchymal, umbilical cord, or bone marrow derived. According to researchers Recent advances in regenerative medicine suggest that the transplantation of stem cells, including embryonic stem cells, neural stem cells, bone marrow mesenchymal stem cells, induced pluripotent stem cells, umbilical cord blood cells, and human embryonic germ cells, focusing on the root of the problem, may provide the possibility of developing a complete cure in treating [cerebral palsy] CP. However, safety is the first factor to be considered because some stem cells may cause tumorigenesis. Additionally, more preclinical and clinical studies are needed to determine the type of cells, route of delivery, cell dose, timing of transplantation, and combinatorial strategies to achieve an optimal outcome. Given the lack of adequate evidence for its efficacy, and the potential for adverse events, stem cell treatments were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result:  Three reviewers determined that the services at issue were not and are 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:   One reviewer is board certified in neurology with sub-specialty certification in pain medicine and metabolism and is actively practicing. Two reviewers are board certified in neurology 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 weekly or biweekly therapy appointments for treatment of his behavioral health condition.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with major depressive disorder.  Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. In this particular case, the patient was enduring an acute episode of illness. Although community programming is an important complementary intervention in any case, Al-Anon and monthly therapy appointments would be both inadequate for therapeutic consolidation.  The meta-analysis by Cuijpers and colleagues identified that at least 18 treatment sessions are needed to realize optimal effects of psychotherapy. In addition, the American Psychiatric Association Clinical practice guideline for the treatment of patients with major depressive disorder state the following, Regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. If 48 weeks of treatment do not yield at least moderate improvement (20% diminution in symptoms), the clinician should thoroughly review and reappraise the treatment plan. Thus, a course weekly individual therapy appointments with systematic monitoring would be safe, appropriate and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, the requested services are medically necessary for treatment of the patients medical condition.  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 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.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. According to the American Psychiatric Publishing Textbook of Psychiatry, TMS therapy is U.S. Food and Drug Administration (FDA) approved for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. In this case, the patient is described as enduring an acute major depressive episode that was causing significant morbidity and functional impairment despite appropriate psychotropic medications and evidence-based psychotherapies for the treatment of depression.  Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represented an appropriate treatment consistent with good medical practice. Although TMS is not indicated for maintenance or preventative treatment, the patient did not complete her initial treatment course.  Thus, it is reasonable to expect that the additional sessions would complete the treatment course, improve the patients condition and prevent a more serious episode of illness. Thus, the services at issue were and are medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested magnetic resonance imaging (MRI) scans of the hands, left knee, and chest (including left back region with ribs seven, eight and nine) for an evaluation of his medical condition. Findings:  The physician reviewer found that it is both reasonable and medically necessary to do an MRI of the patients hands since he has synovitis, and the MRI would show whether synovitis, bone marrow edema, joint effusions, or joint erosions are present. The results of the study would guide further therapeutic decisions. The rationale for MRI of the left knee, chest and ribs is not evident. There is nothing in the medical records that documents the reasons for proposing these studies or what information is expected from them as it pertains to diagnostic value or treatment planning and protocol. Based on the records provided, the patient does not present with any findings that would necessitate MRI scans of the left knee, chest and ribs.
Appeal type: Urgent Care
Decision: Overturned

A 44-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that at issue is whether a reasonable and prudent layperson in the patients circumstance would believe he or she was experiencing an urgent medical condition on the dates of service at issue. Urgently needed services are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plans service area. The acute joint pain experienced by this patient did represent an urgent medical condition which required care without prolonged delay. The submitted evidence demonstrates the patient had a history of similar though less severe symptoms and had been treated for an inaccurate diagnosis. The medications previously used led to side effects with only partial control of the joint symptoms. After arriving in a destination outside of the Plan's service area, he developed a more severe episode, which made it very difficult for him to walk and required the use a cane. He was seen by a physician and appropriately referred to a rheumatologist. The addition of daily medication controlled his symptoms but it was important to determine the mechanism of this joint inflammation, as prolonged treatment with the prescribed medication carries significant risk of its own and would be inappropriate if this acute joint inflammation had been related to infection. For the reasons stated above, a reasonable and prudent layperson in these circumstances would believe this was an urgent medical condition for which treatment could not be delayed until he returned to his Plans service area.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested for radiofrequency ablation for treatment of his lung metastases. Findings:  Three physician reviewers found that there are several reports of the safety of RFA of pulmonary neoplasms, with most of these in patients with lung cancer who are medically unfit for surgery. Additional reports are also published regarding the treatment of pulmonary metastases for control of symptoms. However, there is no data on the efficacy of RFA in prolonging disease survival in either lung cancer or metastatic disease. In this patient, who is asymptomatic and has multiple, bilateral pulmonary metastases, and in whom the largest two lesions are not amenable to either re-section (due to multiple prior surgeries) or even RFA (due to the location of the left lesion adjacent to the mediastinum and the right lesion adjacent to the diaphragm), the denial of RFA should be upheld. Given the multiple lesions, there is no value in treating one asymptomatic lesion, as this offers no palliation (the patient is without symptoms).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg medication, for 12 weeks for treatment of the enrollees hepatitis C infection. Findings:  The physician reviewer found that According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni 90-400 mg for 12 weeks is supported as medically necessary for the treatment of the patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.The submitted documentation fails to demonstrate the medical necessity of the requested medication. In the documentation submitted for review, there is a lack of objective treatment goals for pain and function. When starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long acting opioids. Additionally, when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to greater than or equal to 90 MME per day or carefully justify a decision to titrate dosage to greater than or equal to 90 MME per day.  There was no medical evidence based rationale given for this high of a dosage. The medical literature is clear that dose escalation is not a long term plan, but a short term plan for the treatment of tolerance. Risk and benefit analysis must be performed to justify the requested dose. The records do not show clear objective goals with a higher dose of opioid have been established by the provider or the patient. There is no record of completion of behavior therapy despite much research to support its use. In addition, the medical literature indicates that the use of opioids has been linked to significant problems with treating headaches and may cause continued headaches. Finally, not all non-opioid medications classes have been optimized or tried.  For all these reasons, the requested authorization and coverage for OxyContin, has not been established as medically necessary for treating this 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 anesthesiology with sub-specialty 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: Overturned

The parent of a six-year-old male enrollee has requested speech therapy services for the treatment of the enrollees autism and mixed receptive/expressive language disorder. Findings:  The physician reviewer found that this autistic patient has profound speech delay, yet has developed some academic skills close to age level, which would imply normal or close to normal intellectual capacity. This implies that the possibility of language and communication skills to improve does exist. He presently is functioning at the 1st percentile for both receptive and expressive language.  He has failed to improve communication skills despite fairly intensive speech therapy. Myers and colleagues recommend extensive speech therapy for autistic children. The paper notes that the traditional, low-intensity pull-out service delivery models often are ineffective. Goldsteins paper deals with the potential success of various speech therapy techniques in improving communication skills in the autistic population. This patients pediatrician has been following the patient for at least two years and has recently recommended an increase in the intensity and frequency of speech therapy.  Speech therapy was medically indicated for this patient. Future speech therapy is also medically appropriate, and the patient should be reevaluated in one year to evaluate progress.
Appeal type: Experimental/Investigational
Decision: Upheld

The mother of a 10-year-old female enrollee requested authorization and coverage of vision therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees learning disabilities.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for surgery to remove pancreatic cysts. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested services. Surgical consultation has been performed. The provider recommended against surgery due to the benign nature of the enrollees medical condition. Biopsy was confirmatory for an inflammatory (non-malignant) condition. Pancreatic cyst excision would require enteric reconstruction and resection. The risks of this operation include anastomotic leak, peritoneal sepsis and bacteremia. This patients reports of pain are subjective and felt not to be related to the patients medical condition. Risks of surgery are too high to warrant resection for a benign condition. As such, non-operative management with pain management referral is most appropriate. Therefore, the requested surgery to remove pancreatic cysts is not medically necessary for the treatment of the patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.