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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for lab tests. The enrollee has glioblastoma multiforme, World Health Organization grade IV, estimated glomerular filtration rate gene amplifications positive, monosomy 10 q isocitrate dehydrogenase wild type, methyl guanine methyl transferase negative. The enrollee underwent gross total resection of the right temporal lobe lesion. He was treated with concurrent Temodar from and completed six cycles of high-dose adjuvant Temodar. Literature reports glioblastoma grows rapidly, is highly aggressive, and its clinical outcome is independent of its histological pattern. Professional society guidelines described molecular/genetic testing as additional diagnostic to aid in prognostic information, but cautioned it should not be used in place of standard histologic assessments. The guideline also noted there were no identified agents which demonstrated effectiveness for treating glioblastoma. Testing for glioblastoma has not shown to show improvement in treatment options, and does not change the prognosis of the disease. The results of the tests did not modify the treatment recommendation for this enrollee as the enrollee had no evidence for recurrence.Final Result: Two of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology 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

The mother of a 16-year-old male enrollee requested authorization and coverage of continuing physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees spastic quadriplegia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested a cochlear implant external processor replacement for treatment of her hearing loss.   Findings:  The physician reviewer found that the cochlear implant is useless unless there is a functional external processor that can be appropriately adjusted. The patients current processor outlived its usefulness. It was medically appropriate and indicated to replace that device. There was no alternative available for the patient and the processor at issue was integral to her hearing and was indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested authorization and coverage for partial hospitalization program level of care with evidence-based treatments for post-traumatic stress disorder and depression.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  The patient requires intensive evidence-based psychotherapy for her major depressive disorder and post-traumatic stress disorder.  Due to this patients co-occurring depression and post-traumatic stress disorder, the literature suggests that this patient is at high-risk for suicide.  Her condition has been treatment-resistant, and she has failed the outpatient treatment setting.  The patient has required treatment in the inpatient setting twice in the past two months.  Although the inpatient setting can help negotiate pressing crises, it cannot approach resolution of the underlying intrapsychic conflicts that fuel a symptom complex, such as in this patients case.  Per the American Psychiatric Association guidelines, the determination of the appropriate level of care should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.  The peer-reviewed literature supports the requested services in this patients case.  All told, the requested partial hospitalization program level of care with evidence-based treatments for post-traumatic stress disorder and depression is medically indicating for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested intravenous immunoglobulin (IVIG) therapy for the treatment of the enrollees myasthenia gravis. Findings:  The physician reviewer found that the documentation from the patients mother indicates the patient is currently stable and they are not requesting coverage of IVIG at this time. The request for IVIG is for a preauthorization for use if the patient develops myasthenic crisis. The use of IVIG acutely is standard therapy for myasthenic crisis with proven results. As the study by Chiang and colleagues indicates, juvenile MG is different from adult MG and IVIG is often the only therapeutic intervention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an appointment with the Psychiatry Department. The patient presented for a mental health assessment and was referred to addiction medicine. Subsequently, the patient requested treatment for her escalating alcohol problem. As noted in the current medical literature, a patients substance abuse issues must be addressed prior to her issues of depression, poor concentration, and excessive worry. The symptoms reported by the patient of depression, anxiety, poor concentration, and excessive worry are connected with active substance abuse. This patient was referred for early intervention or CDRP, which is appropriate in this clinical setting. Thus, a patients substance abuse issues must be addressed first. After a patient has addressed their substance abuse issues, a follow-up mental health assessment can be provided to determine if the patient requires additional services. Given these findings, the appointment with the Psychiatry Department is not medically necessary for treatment of this patients behavioral health issues. 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 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: Upheld

A 28-year-old female enrollee has requested Subsys 600mg sublingual spray for treatment of her intractable migraine headaches. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient reportedly has refractory migraine.  The medical records do not describe headache frequency.  However, the use of opiates on a daily basis implies chronic daily pain, and thus chronic migraine.  Frequent analgesic use is known to result in transformation of episodic to chronic headache.  The medical records indicate prior use of multiple preventive medications. However, there is evidence that response to preventive medications can be hindered by opiate use.  There are preventive medications that do not appear to have been used in this patients case, including oral methylergonovine and Botox.  The latter is U.S. Food and Drug Administration (FDA) approved for chronic migraine, has good tolerability, and may be beneficial as opiates are being weaned.  All told, Subsys 600mg sublingual spray is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatologist referral for evaluation of the enrollee who presented with a suspicious mole. Findings:  The physician reviewer found that the request for coverage of dermatology referral should be approved. The size of the area is estimated at 2.5 cm. Dermatologists have specialized training in the evaluation of nevi and other skin growths. The medical literature shows that dermatologists are able to detect thinner lesions and are able to detect them at an earlier stage than those melanomas diagnosed by other physicians. Additionally, there is a family history of skin cancer, and the primary care provider recommended an evaluation by a dermatologist. Based on these considerations, a referral to dermatology department for evaluation and consideration for a biopsy is consistent with medical necessity. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients and genotype 4 patients. Although the guidelines do recommend the Health Plans alternatives (Zepatier and Harvoni) for genotype 4, these medications have not shown effectiveness for genotype 3. Epclusa is the only AASLD/IDSA-recommended medication that is effective for both genotype 3 and 4. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, for Epclusa is medically necessary for the treatment of this patient. 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: Overturned

The enrollee has requested authorization and coverage for Euflexxa injections. As evidenced by the history of significant benefit from these injections in a large number of patients; the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Given this patients clinical presentation and prior treatment with NSAIDs and corticosteroid injections, viscosupplementation for longer term pain relief is medically necessary. Therefore, Euflexxa injections of the right knee are medically necessary.Final Result: The reviewer determined that the requested treatment 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for a breast magnetic resonance imaging (MRI) that was provided. The Health Plan has denied the service at issue as investigational or experimental for evaluation of the enrollees breast health.Findings:  Two out of three physician reviewers found that contrast enhanced breast MRI is more sensitive for the detection of breast cancer in the high-risk population, approximately 90 percent sensitive, than both mammography and ultrasound, approximately 38 percent individually. Screening breast MRI is recommended in patients with a lifetime risk of greater than 20 percent, patients with BRCA gene mutations and their untested first-degree relatives as well as other high-risk populations. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. In this case, the patients calculated lifetime risk of breast cancer is above 20 percent, and therefore, breast MRI is indicated. Screening mammography is also recommended, although the patient defers at this time. Thus, the breast MRI that was provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One physician reviewer found that the breast MRI that was provided was 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 service at issue was 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: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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 male enrollee requested a computed tomography (CT) scan of the chest for medical evaluation of his dysphagia, palpitations, and abdominal pain.   Findings:  The physician reviewer found that according to the American College of Radiology (ACR), the appropriate initial radiographic examination after a normal chest x-ray would be a barium esophagram. Following this study, if indicated, the patient should proceed with the endoscopic procedure as recommended by his primary care provider. Only if there is an abnormal finding on EGD or even the esophagram would a CT be considered for evaluation of dysphagia. For these reasons, the requested CT of the chest is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested an epidural steroid injection for treatment of his spinal stenosis.  Findings:  The physician reviewer found that Abdi and colleagues performed a systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and criteria of Cochrane Musculoskeletal Review group for randomized trials. The authors found that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given the patient did not experience long-term relief (greater than six weeks), or demonstrate reduced use of medications and adjunctive therapy such as physical therapy, heat and ice with the first epidural steroid injection, a repeat epidural steroid is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for allergy testing. Given the history and physical examination findings noted in the medical records, the likely diagnosis for this patients skin condition is atopic dermatitis (AD). There is adequate evidence in the medical literature to support testing for foods to help determine the aggravators of the underlying disease in this clinical setting. Researchers found that, The diagnosis of food allergy in AD is currently based on the clinical history, skin prick tests, or blood test screening, followed by an elimination diet and/or standardized oral food challenge. For this patient, it is appropriate to perform food allergy testing to rule out any potential food triggers. Accordingly, the requested allergy testing is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology 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 four-year-old male enrollee has requested coverage for two hours of speech therapy per week which were removed by the Health Plan from the treatment plan.  The enrollee has been diagnosed with autism. Findings:  The physician reviewer found that autism spectrum disorder is a complex neurological disorder with characteristic deficits in speech/language and social interaction.  There are likely a multitude of etiologies, with clinical symptoms being the common denominator.  Oftentimes, there are other concurrent diagnoses, such as genetic conditions or mental health issues.  There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in these children. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, social skills training, and behavioral therapy. Fundamental to the diagnosis of autism spectrum disorder are deficits in speech and language.  The medical research has shown that early intervention focused on communication and social skills can significantly improve the outlook for patients on the spectrum.  Verbal apraxia, or apraxia of speech, involves impairment in planning and coordinating movements for speech production.  While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired.  This is a deficit in motor programming and sensorimotor processing at the central level.  It is a neurological disorder that requires intensive treatment, as communication at all levels may ultimately be impaired.  Children on the autistic spectrum have deficits in speech and language, as well as social communication.  Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate.  All told, two hours of speech therapy per week which were removed by the Health Plan from the treatment plan are medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees shoulder and upper arm pain. Findings:  The physician reviewers found that current accepted standards of care do not support an indication for the requested lower extremity MRI study for this patient on the basis that the medical records do not indicate any physical exam findings of joint looseness or tendon impingement. In addition, there is no documentation of a course of physical therapy that has been attempted and failed. Moreover, the medical records also do not document a trial of non-steroidal anti-inflammatory meds or acetaminophen for three or more weeks, which is also an accepted standard of care treatment prior to MRI study being performed. Thus, the requested lower extremity MRI is not supported as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested diagnostic procedure is 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 reviewers number one, two, and three are board certified in diagnostic radiology and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for insulin pump. Findings:  Three physician reviewers found that a continuous glucose monitoring system records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. This device can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. Studies have shown that use of a continuous glucose monitoring system can help optimize glycemic control and can lead to even greater improvement when used in conjunction with insulin pump therapy. The U.S. Food and Drug Administration recently approved the closed-loop insulin delivery system for use in patients with type 1 diabetes who are at least 14 years of age. The system uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor. The medical evidence supports the requested device in this setting. Therefore, the requested insulin pump is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.