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

A 30-year-old female enrollee has requested substance abuse residential treatment services for the treatment of her pain medication addiction and chronic pain. Findings:  The physician reviewer found that the patient suffers from multiple diagnoses, and has had a rapidly shifting approach to her various medications. Unquestionably, she had a chronic pain syndrome, though the multitude of her somatic complaints is such that it is surprising that she was not also considered to be experiencing Somatization Disorder. However, to the extent that she was consistently cited in the submitted treatment notes as better, there appears to be nothing to support the notion of her warranting services as intensive as residential treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SelectMDx genomic testing provided by MDx Health, Inc. The records provided for review document that this patient has a history of elevated prostate specific antigen (PSA) and enlarged prostate. The patient underwent testing with SelectMDx genomic analysis, which demonstrated 38% likelihood of prostate cancer on biopsy, and a 13% likelihood of detecting Gleason score 7 or greater cancer. As noted in the peer-reviewed medical literature, prostate biopsy is an invasive procedure with limited risk for infection, prolonged discomfort, or urinary issues. While reducing unnecessary biopsies drives the use of genomic testing after PSA and Free PSA offer questionable guidance, there is a paucity of support for use of the SelectMDx genomic testing for further evaluation of this patients elevated PSA and enlarged prostate. Although data are emerging which support further study of genomic testing, its use is not likely to yield superior health outcomes in this patients clinical setting based on current studies when compared to the current standard of care including biopsy. All told, the SelectMDx genomic testing provided by MDx Health, Inc. was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in urology and is actively practicing. Physician reviewer 2 is board certified in urology and is actively practicing. Physician reviewer 3 is board certified in urology with subspecialty certification in in urological surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Relpax. The Health Plan indicated that the eletriptan may be considered for approval after a trial and inadequate response or intolerance to both generic Imitrex and generic Amerge.Peer-reviewed publications support Relpax for abortive treatment of migraine headaches. A.A. indicated that Relpax was approved by the Food and Drug Administration (FDA) and is used for the abortive treatment of migraine headaches. Studies noted that Relpax was approved by the FDA and is used for the abortive treatment of a migraine headache. It is recommended to be used up to two times per week.  The medical records document headache frequency, severity, and associated signs and symptoms with demonstration of a diagnosis of migraine headaches. With a demonstrated diagnosis of migraine headaches, Relpax is supported as medically necessary for the patients medical condition and therefore, the Health Plans denial should be overturned.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 reviewer is board certified in neurology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 75-year-old female enrollee has requested a wearable cardioverter defibrillator for treatment of her cardiomyopathy.  Findings:  Two physician reviewers found that the patient presents a clinical dilemma due to the fact that she does not qualify for a permanent ICD according to current guidelines, but is at high risk for sudden death given the severe LV dysfunction, severe LV dilatation, and LBBB. Since her symptoms were present for months, there is low likelihood that meaningful recovery in LV function will occur with optimal medical therapy. In this clinical setting, the peer-reviewed medical literature shows that the wearable cardioverter defibrillator plays an important role in reducing the risk of sudden death in such patients. Therefore, use of the wearable cardioverter defibrillator in this patient was medically appropriate and likely to have been more beneficial than any available standard alternative.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee requested authorization and coverage of Silikon 1000 injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees HIV-related lipodystrophy.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sinus tarsi implant with HyProCure device to right and left feet. Findings:  The physician reviewer found that data reports promising results on the efficacy of subtalar arthroereisis in children, its use in adults remains unsubstantiated in the peer-reviewed medical literature. In adults with a less flexible deformity, treatment usually requires other surgical procedures involving the posterior tibial tendon or calcaneal osteotomes to effectively improve the patients condition. Bernasconi and colleagues noted that sinus tarsi pain is the most frequent complication, often requiring removal of the implant. Moreover, the authors found that, poor quality evidence is available in the literaturewith only one comparative non-randomized study (Level II) not providing strong recommendations. All told, the requested sinus tarsi implant with HyProCure device to right and left feet is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested sinus tarsi implant with HyProCure device to right and left feet is not 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 not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in podiatric surgery and is actively practicing. Physician reviewer 2 is board certified in podiatric surgery and is actively practicing. Physician reviewer 3 is board certified in podiatric surgery and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for ketamine assisted psychotherapy services. Findings:  Three physician reviewers found etamine is a dissociative drug commonly used as an anesthetic in veterinary practice. Ketamine is not approved by the United States Food and Drug Administration (FDA) for treatment of psychiatric illness, but its off-label use is becoming more common. The duration of action of ketamine is rather brief, while the poor bioavailability of oral ketamine has prompted the use of intramuscular, intravenous and intranasal delivery systems.  In addition to the difficulty delivering the medication, the lack of adequately-powered, long-term studies raises potential concern regarding the safety, addictiveness and longstanding effects of ketamine therapy. Further, the medical records do not demonstrate treatment refractoriness or the exhaustion of standard therapies available to treat the patients condition. In sum, ketamine assisted psychotherapy services were not and are not likely to be of greater benefit than other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees language delay. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  In this patients case, she demonstrates significant receptive and expressive language delay that is negatively impacting her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia services during dental work to be performed in a hospital or surgical setting. The Health Plan has denied this request indicating that the requested services are not medically necessary for management of the enrollees dental condition. Findings: The submitted documentation supports the medical necessity for the requested services in this clinical setting. The patient has a number of medical conditions that jeopardize her ability to tolerate outpatient management and the use of local anesthetic or conscious sedation. The standard calming techniques and communication cannot be completely successful at her age. The provider indicates that she has extensive dental caries and requires a lot of restoration, resulting in a long procedure time, increasing her risk of morbidity should her airway not be adequately protected. Per Department of Health Care Services (DHCS) criteria, if the patient requires extensive dental restoration or surgical treatment, if use of effective communicative techniques and immobilization was not successful, if the patient has acute situational anxiety due to immature cognitive functioning, or if the patient is uncooperative due to certain physical or mental compromising conditions, then general anesthetic should be considered. This patient meets these criteria. Based on the current standard of care, the requested general anesthesia services during dental work to be performed in a hospital or surgical setting is medically necessary to allow for complete dental restoration for this patient.Final Result: The reviewer determined 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 pediatrics 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 parent of a two-year-old male enrollee has requested Bone Anchored Hearing Aids (BAHA) for treatment of the enrollees CHARGE syndrome with bilateral hearing loss.  Findings:  The physician reviewer found that in the current published peer-reviewed medical literature, Hakansson and colleagues reported that improvements in traditional bone conduction aids have made them comparable to the soft band devices. In a study from Verhaegen and colleagues, the researchers recommended conventional amplification devices or cochlear implantation in patients with severe sensorineural hearing loss. The authors concluded that a cochlear implant is a valuable option in patients with mixed hearing loss when the sensorineural hearing loss component exceeds 70 dB. From a review of this patients records, the degree of the hearing loss has not yet been established. Further, the soft band BAHA devices have not been demonstrated to be superior to conventional hearing aids in this patient population. For these reasons, the requested soft band BAHA devices have not been established as medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male who was treated for hepatitis C in February 2004. In light of his history of cirrhosis the patient is now being continued on Pegasys for maintenance purposes to prevent transplantation. The Health Plan indicates since the patient did not respond to previous therapy, continued Pegasys therapy is not medically necessary. The Health Plans denial should be upheld. The use of Pegasys as maintenance therapy is of unproven efficacy. The HALT-C study is an ongoing study and its conclusions and results have not become the standard or the community care. Short of the HALT-C program, there is no prospective, double-blind study looking at the maintenance issue. As such, there is insufficient evidence at this time that the requested therapy is likely to be effective for patients such as this patient. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female has requested intensity modulated radiation therapy (IMRT) for treatment of large B-cell lymphoma.   Findings:  Two physician reviewers found that the patient presents with non-Hodgkins lymphoma with a bulky epigastric mass, which was diagnosed approximately two years ago. She underwent chemotherapy with R-CHOP and had a response with no signs of progressive disease after eight cycles. Following chemotherapy, she was treated with tomotherapy over 18 fractions to a total dose of 36 Gy to her initial site of bulky disease. There is no evidence in this patients records to suggest that standard treatment with 3D conformal technique to deliver radiotherapy would result in more side effects than expected with IMRT. Further, because lymphoma is a relatively radiosensitive tumor, the dose prescribed in this case was 36 Gy. At the prescribed dose of 36 Gy, it is unlikely that an IMRT treatment plan would result in any clinically meaningful decrease to the surrounding normal structures compared to a 3D conformal plan. Therefore, treatment with IMRT was not likely to be more beneficial than the standard therapy of 3D conformal radiotherapy in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee has requested a cardiology consultation and stress testing for evaluation of his irregular heartbeat, shortness of breath and dizziness.  Findings:  The physician reviewer found that the patients records indicate the presence of some cardiac risk including a family history of coronary artery disease (CAD), in addition to hypertension and a normal appearing electrocardiogram. The patients symptoms of exertional dyspnea and palpitations are concerning for an ischemic equivalent. In this clinical setting, further evaluation with stress testing is reasonable, appropriate, and considered within the accepted standard practice in the medical community. The current guidelines, as discussed by Gibbons and colleagues, are endorsed by several national organizations including the American College of Cardiology (ACC) and the American Heart Association (AHA). The recommendations consider stress testing appropriate in the clinical circumstance of a patient with cardiac risk and symptoms of dyspnea suggestive of an ischemic equivalent.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee has requested 30 days of inpatient residential treatment for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) placement criteria, the patient is an appropriate candidate for treatment in a less restrictive setting than residential treatment level of care. Per the ASAM guidelines, this patient has not shown any acute withdrawal symptoms and is not at significant risk for severe withdrawal. The records indicate that he has been able to limit his use to the weekends only. The patient has no documented medical conditions or complications that would require continuous 24-hour monitoring and care. Further, the patient has been motivated to change. While the patients recovery environment is not supportive, he could be safely treated in a sober environment, such as a half-way house. As the patient continues to require close monitoring and support several times a week, services can be provided at the intensive outpatient program (IOP) or partial hospitalization program (PHP) level. Consistent with these findings, the requested residential level of care is not supported as medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee has requested adult psychiatric residential treatment services for the treatment of her major depressive disorder and anorexia nervosa. Findings:  The physician reviewer found that this patients history of intense abandonment issues, her past suicidal attempts including a gesture while in residential treatment, her history of psychotic decompensation and past acute hospitalizations, there was a need to maintain the level of care provided to avoid further decompensation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old man with a history of bilateral ptosis. The patient is status post multiple eyelid procedures. The patient states he is concerned about the appearance of his right eyelid and wishes to undergo another surgical procedure to correct the defect. No evidence of visual field tests has been provided. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The submitted documentation does not demonstrate the requested procedure is medically necessary. There is no evidence of field loss or exposure keratitis. The submitted photographs show only a mild ptosis that would not interfere with vision. Furthermore, fine-tuning ptosis repair with a second or third procedure can be problematic. As such, 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: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested extracorporeal shockwave therapy for treatment of his Achilles tendonitis and right ankle bone spur.  Findings:  Three medical professional reviewers found that although ESWT has been shown to be effective for treatment of lateral epicondylitis of the elbow and plantar fasciitis, it remains investigational for treatment of the patients condition. There are no documented studies showing ESWT has long-term effectiveness for Achilles tendonitis. Furthermore, there are other available modalities such as physical therapy that are likely to be effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for oxygen therapy. Indications for continuous long-term oxygen therapy include resting arterial oxygen tension less than or equal to 55 mmHg, a pulse oxygen saturation less than or equal to 88%, cor pulmonale, right heart failure, or erythrocytosis. In this case, the patient does not qualify for long-term oxygen therapy. His chest x-ray, spirometry and arterial blood gases were normal, which rule out any significant lung disease. Therefore, the requested oxygen therapy is not medically necessary.Final Result: The reviewer determined that the requested service 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 internal medicine with subspecialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.