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

A 64-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breasts for an evaluation of her fibrocystic breast changes.  Findings:  The physician reviewer found that there are several indications for MRI of the breast, which include a determination of the pre-operative extent of cancer, post-operative extent of residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High-risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. This patient would be considered high-risk because of her personal history of breast cancer, which is a clinical indication for breast MRI.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested endoscopic reduction of gastric stoma for treatment of her complication of gastric bypass.  Findings:  Three physician reviewers found that Gastrogastric fistulas are a known complication of gastric bypass, but found to occur in a much higher percentage with open and non-divided gastric bypass techniques. As many as 15% of patients with gastrogastric fistulas are from open gastric bypass surgery. Endoscopic repair techniques have not been shown to have durable weight loss or durable repair of fistulas. This patients small disruption is unlikely the cause of her weight regain, which occurred over a seven year period. In addition, this patient has documented poor dietary habits and did not undergo any form of multidisciplinary evaluation for endoscopic revision. All told, the requested services are not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of an eight-year-old male enrollee has requested computerized gait analysis for evaluation of the enrollees abnormal gait. Findings:  Three physician reviewers found that the relevant peer-reviewed medical literature supports computerized gait analysis in surgical decision-making process in children with neurologic disorders such as cerebral palsy. To date, there is insufficient scientific data demonstrating that computerized gait analysis is the equivalent of, or superior to, standard clinical evaluation performed by a qualified orthopedic surgeon in patients without a diagnosed neurological disorder. In this patient with intoeing from excessive femoral anteversion without evidence of a neurologic disorder, the use of the requested services has not been established as likely to be more beneficial in his evaluation and treatment than conventional evaluation modalities readily available.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 19-month-old male with plagiocephaly and congenital torticollis. The plagiocephaly has been treated since the age of eight months. He outgrew the first band and subsequently received a second band. The family is requesting reimbursement for the continued orthosis treatment with a second DOC band. At issue is whether continued treatment with a second DOC cranial band was medically necessary for treatment of the patients medical condition.Review of developmental medicine and child neurology literature shows that DOC bands can benefit patients with plagiocephaly if initiated before the age of one year, as was the case with this patient. Although there is no level I or II literature available on the results in older children, there is some evidence that continuation of band therapy may be beneficial up to age two. The use of DOC banding in patients who have plagiocephaly with torticollis is medically reasonable and appropriate. Since torticollis is the underlying cause of plagiocephaly in this patient, aggressive treatment for the torticollis should also occur. Based upon the information at this time, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hysterectomy surgery. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Per current standard of care, a hysterectomy is considered medically necessary for the treatment of abnormal uterine bleeding when investigation has not identified specific etiology of abnormal uterine bleeding through bloodwork and imaging, hormonal therapy was tried but did not adequately treat the condition, and a uterine-sparing procedure (e.g. endometrial ablation) cannot be used. In this case, the clinical documentation reflects that the patient was evaluated by a urogynecologist and counseled for total vaginal hysterectomy and tension free vaginal tape. The submitted documentation includes the medical note for this office visit, during which alternatives such as an intrauterine device and endometrial ablation were reviewed. However, in provider correspondence written since hysterectomy was performed, the provider states that the patient's surgical history of cesarean section and bowel resection contraindicate her ability to undergo these therapies. Neither cesarean section nor history of bowel resection are true contraindications for either alternative therapy. Furthermore, there is no clinical documentation to support a thorough investigation for specific etiologies including screening for abnormal cells/malignancy. Per the American College of Obstetrics and Gynecology, a patient of this age should undergo an endometrial biopsy to rule-out malignant cells. While the provider states in post-hysterectomy correspondence that it was not indicated for an endometrial biopsy to have been performed, the provider does not explain or document their basis for this statement. Given the patients irregular bleeding pattern, as documented in the clinical notes, it would be expected that the patient would have undergone an endometrial biopsy prior to hysterectomy. In sum, the hysterectomy surgery was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services in issue were 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 obstetrics and gynecology 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 39-year-old female enrollee requested authorization and coverage of a referral to a pain management specialist for the treatment of arthritis, calcium build up and bone spurs.  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 referral is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 7-year-old male enrollee has requested  2 hours per week of in-home speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that in this case, the patient is a 7-year-old autistic male with expressive and receptive language equivalencies of a 9-month-old. The record indicates that he has minimally grasped the technique of utilizing an I-Pad computer tablet to assist with communication. Thus, individual speech therapy utilizing the I-Pad communication device may facilitate language utilization despite his developmental delays (Pickett, et al). One hour of speech therapy per week is an appropriate frequency to attempt to promote the patients utilization of a computer speech-facilitator. As such, speech therapy for one hour per week on an individual out of home basis is medically necessary in this clinical setting. In-home speech therapy is not medically indicated as this patient attends school outside the home and is not home bound. Therefore, based on the medical literature cited above and the documentation submitted for review, speech therapy outside the home for 1 hour per week is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One injections. Findings: Two of the three physician reviewers found that there is sufficient support for the requested services in this patients case. This patient has benefitted from prior viscosupplementation. Per the current literature, intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. The authors reported that viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, Synvisc-One injections are likely to be more efficacious than other available treatment options. 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 reviewer 1, 2 and 3 are board certified in orthopedic surgery 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Myrbetriq 50 mg. Findings:  The physician reviewer found that there is a lack of documentation from the provider in the medical records reviewed that this patient has completed an adequate trial of oxybutynin. Currently, Myrbetriq is considered a second-line therapy for this patients progressive urinary frequency and incontinence. In the absence of records demonstrating that the patient has failed an adequate trial of a first-line therapy such as oxybutynin, the requested Myrbetriq is not supported as medically necessary. 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 urology 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: Upheld

Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for Lynparza.  Findings:  The physician reviewer found that Lynparza is one of a newer class of drugs referred to as poly-ADP-ribose polymerase (PARP) inhibitors. Their use has particularly focused on cancers that arise in BRCA positive patients. Indeed, the drug is quite useful in BRCA positive ovarian cancer, as well as metastatic breast cancer. Efforts directed at exploring its use in cancers other than breast and ovarian cancers are underway. Responses have been reported in pancreatic and prostate cancers. However, there is minimal evidence for the efficacy of Lynparza in patients with lung cancer. Therefore, Lynparza 100 mg tablets #180 for 30 days x 11 refills is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Two physician reviewers found Lynparza 100 mg tablets #180 for 30 days x 11 refills is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that Lynparza 100 mg tablets #180 for 30 days x 11 refills is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and are actively practicing. Physician reviewers 1 and 3 are board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Upheld

A 50-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia. Findings:  The physician reviewer found that it is not clear from the record whether the patients symptoms are due to fibromyalgia or a primary depression with secondary sleep disturbance and associated depressive symptoms. The reported sleep disturbance with recurrent wakening at 4 am is a classic symptom of depression. It is also possible that the patients depression is secondary to fibromyalgia. Nonetheless, assuming a primary diagnosis fibromyalgia, it does not appear from the record the patient has been treated with any of the agents typically used for this condition. Given the prominence of depression-related symptoms, a trial of at least one antidepressant as well as Neurontin is reasonable. Should such trials prove ineffective, then treatment with Lyrica would be appropriate as it is the only agent specifically approved for the treatment of Fibromyalgia. Additional medication failures should not be required.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lumbar spine magnetic resonance imaging (MRI). Findings:  The physician reviewer found that diagnostic imaging may be indicated for patients with low back pain only if severe progressive neurologic deficits or signs or symptoms suggest a serious or specific underlying condition, and that in other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. The American College of Radiology (ACR) appropriateness criteria note that for acute, subacute, or chronic low back pain, with or without radiculopathy, an MRI of the lumbar spine is usually not appropriate without red flags or prior management; however, the guidelines note that an MRI of the lumbar spine may be appropriate following six weeks of optimal medical management with persistent or progressive symptoms. In this case, the patient was treated for acute onset of left-sided low back pain with left-sided sciatica. While she was treated with medication management and one chiropractic session, the submitted records do not show trial and failure of recent and reasonable conservative care measures. Given that imaging is not indicated in the absence of fully documented severe progressive neurologic impairments without trial and failure of optimal medical management, the requested service is not medically indicated. Therefore, a lumbar spine MRI is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld

The patient is a 61-year-old male with a history of alcohol abuse who has been hospitalized twice in the last eight months.  He participated in skilled rehabilitation following each of his acute hospital discharges.  The patient reports a fall in December 2005 and difficulty with transfers thereafter.  Apparently a hospital bed was delivered several months ago, and never picked up by the vendor.  The patient does not have a bed of his own and has requested authorization of the hospital bed for an additional six months.  The Health Plan has denied his request based upon a determination that the hospital bed is not medically necessary.Upon review of the information there is no documented medical necessity for the requested hospital bed.  The patient has some instability of gait due to chronic alcoholism for which he uses a walker or cane.  It was noted that his transfers required stand-by assistance (SBA) at the time of discharge from the hospital in December 2005. There is no documentation of impairment in bed mobility.  Furthermore, the documentation indicates the patient has no regular bed, but he could function as well as he does with the hospital bed if he had a regular bed.  The enrollees primary complaint is that he cannot transfer from the floor where he sleeps to an upright position.  This however, does not constitute medical necessity for a hospital bed.  Therefore, I have determined the requested equipment 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 Gilenya for treatment of her medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient has evidence of clinically definite multiple sclerosis. A patients treating provider determines the best therapy for multiple sclerosis patients based on many different factors, including age, disease activity, MRI findings (ongoing active disease as demonstrated by enhancement), family history, presenting features, and co-morbid disease. The study by researchers compared the effect of oral immunomodulator fingolimod with all injectable immunomodulators (interferons or glatiramer acetate) in patients with active multiple sclerosis. They demonstrated that Gilenya is better than platform agents. In addition, Gilenya is recognized as one of the more highly active multiple sclerosis treatments, and general consensus among many multiple sclerosis specialists is that it is more effective than platform agents, such as interferons and Copaxone. Gilenya is U.S. Food and Drug Administration (FDA) approved for the treatment of relapsing forms of multiple sclerosis and is indicated for patients at any stage of their disease. There is a lack of clinical evidence to suggest that treatment with Gilenya should be held until a patient has tried and failed other disease modifying agents. All told, the medical necessity for treatment with Gilenya has been established in this clinical setting. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The EE has requested authorization and coverage for weekly individual therapy sessions, weekly dialectical behavior therapy (DBT) skills group, and DBT coaching for one (1) year. DBT is typically used for patients with the diagnosis of borderline personality disorder. However, as the therapy techniques in DBT are related to emotion regulation, interpersonal skills, affect of instability, and distress tolerance, it appears that these skills could be clinically useful for this patient (Neacsiu, et al.). The evidence base indicates that patients experiencing suicide ideation as well as self-harm and emotional regulation can benefit from DBT. Specifically, DBT has been shown to be an effective treatment for reducing suicidal ideation and para-suicidal behavior while improving emotion regulation and symptoms of anxiety in patients without borderline personality disorder (Gunderson, et al.). DBT focuses on implementing coping skills in patients with emotion regulation issues. The progress notes provided for review indicate that this patient has experienced steadily worsening symptoms over the past two to three months. The progress notes reflect interpersonal and family problems as well as suicidal ideation. The patient has been treated in an intensive outpatient program (IOP) and partial hospitalization program (PHP) but he continues to have symptoms. The current standard of care for DBT includes individual and group therapy for approximately one year. Therefore, the requested weekly individual therapy sessions, weekly DBT skills group, and DBT coaching for one (1) year are medically necessary for 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 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.