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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for venlafaxine 37.5 mg immediate-release tablets (60 tablets with two refills). The U.S. Food and Drug Administration (FDA) notes that venlafaxine extended-release (brand name Effexor XR) is included in a class of medications called serotonin and norepinephrine reuptake inhibitors (SNRIs) and approves its use for the treatment of major treatment disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder. Stahl and colleagues note, Venlafaxine is available as an extended-release formulation (venlafaxine XR), which not only allows for once-daily administration, but also significantly reduces side effects, especially nausea. In contrast to several other psychotropic drugs available in controlled-release formulations, venlafaxine XR is a considerable improvement over the immediate-release formulation. The immediate-release formulation of venlafaxine has actually fallen into little or no use because of unacceptable nausea and other side effects associated with this formulation, especially when venlafaxine immediate-release is started or when it is stopped. However, venlafaxine even in controlled-release formulation can cause withdrawal reactions, sometimes quite bothersome, especially after sudden discontinuation from high-dose, long-term treatment. Nevertheless, the controlled-release formulation is highly preferred because of enhanced tolerability. In general, physicians prescribe the extended-release formulation of venlafaxine due to a higher rate of moderate-to-severe discontinuation symptoms with the use of the immediate-release formulation of the medication, including dysphoria, headaches, nausea, irritability, emotional lability, sensation of electric shocks, and sleep disturbance. Medication compliance rates with the extended-release formulation, which only requires one dose daily, tend to be higher than with the immediate-release formulation, which may require two to three doses daily. The extended-release formulation is also associated with less nausea and dizziness at the initiation of therapy as compared to the immediate-release formulation. In this case, the records do not indicate that the patient has been trialed on venlafaxine ER, any of the other SNRIs, or any selective serotonin reuptake inhibitor antidepressants (SSRIs). Therefore, venlafaxine 37.5 mg immediate-release tablets (60 tablets with two refills) are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for proton beam therapy.There is a lack of support for the requested service in this clinical setting. Researchers performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, the authors found no difference in disease control between the two modalities. A position statement released by The American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. In this case, the patient has been diagnosed with prostate cancer. There is insufficient medical evidence to support proton beam therapy for the treatment of prostate cancer. Therefore, the requested proton beam therapy is not medically necessary for treatment of the patients medical condition.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 radiation oncology 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 patients parent has requested authorization and coverage for weekly speech therapy. Researchers describe autism spectrum disorder (ASD) as a neurodevelopmental disorder defined by deficits in social communication and the presence of restricted and repetitive behaviors and interests. The authors note that treatment involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Researchers report that the Coronavirus disease (COVID-19) pandemic has created a high degree of disruption to life and stress to families living with an individual with ASD. Researchers report, `The ongoing COVID-19 emergency has resulted in a challenging period for most ASD individuals and their families, with increased difficulties in managing daily activities and at least one in every three children presenting with more frequent or more intense behavior problems. In this case, the patient has ASD, and while repeated administration of standardized testing has not documented progress, the provider reports significant improvement in functional speech. Children with ASD may have attention difficulties using remote services such as telehealth services that the patient has been receiving during the pandemic. Given current medical literature and the providers recommendation for continued therapy, the requested services are medically indicated. Therefore, weekly speech therapy is medically necessary for the 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 neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Three physician reviewers found that the laparoscopic sleeve gastrectomy is a well-established procedure for the treatment of morbid obesity. The safety and efficacy of the sleeve gastrectomy has been sufficiently studied.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for the medications, Percocet, 5mg, at a frequency of eight (8) pills per day, and Norco, 10mg, at a frequency of six (6) pills per day. The enrollee has lumbar radiculopathy. He has a history of lumbar fusion, myofascial tender points and osteoarthritis. It is aggravated by activity and relieved with pain medications, ice, and heat. He underwent a right knee steroid injection, bilateral lumbar medial branch blocks with poor response, a lumbar epidural steroid injection without relief, bilateral L5-S1 transforaminal epidural steroid injections, and sacroiliac joint injections with minimal relief. The enrollee was recommended for the chronic pain level 2 program, but he is not interested in doing these classes at this time. Regulatory agency guidelines describe opioid prescribing as part of a comprehensive, multidisciplinary, multimodal treatment plan in which enrollees are assessed and closely monitored. Due to the addictive risk of opioids, the agency recommends benefits and harms be evaluated within one month of prescribing, and every three months thereafter, to reevaluate the medical necessity for opioid use. Based on this enrollee's medical records, the enrollee refused clinician recommended evaluations including the lumbar spine magnetic resonance imaging scan to assess the pain severity. This point is important, because a magnetic resonance imaging scan can help determine if there is a new source of pain. If this is the case, prescribing an opiate will be masking the pain and prevent the potential workup needed to discover the problem that is at the root of this pain. Medical records indicate the enrollee is not interested in a multidisciplinary, multimodal treatment plan and is only interested in opioids at this time. Given that opioids in this case would not be part of a multimodal pain treatment plan, the medical necessity is not substantiated.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pain management 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a five-year-old male enrollee requested authorization and coverage of continued speech therapy for the treatment of severe receptive and expressive communication impairments and verbal apraxia.  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 overturned the health plans denial on the basis that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested a referral to pain management department and/or treatment with acupuncture for treatment of the enrollees ovarian cysts.  Findings:  The physician reviewer found that although there has also been a growth in acupuncture research, at this time the findings from numerous literature reviews indicate there is inconclusive evidence to support the use of acupuncture to treat reproductive health complaints. The symptoms of the menopause and dysmenorrhea have been subject to greater clinical evaluation through randomized clinical trials and the evidence summarized in systematic reviews than any other reproductive health complaint. Overall, the evidence for acupuncture to treat dysmenorrhea and menopause remains unclear, due to small study populations and the presence of methodological bias. Acupuncture to treat premenstrual syndrome, polycystic ovarian syndrome and other menstrual related symptoms has not been as widely studied, and the evidence for acupuncture to treat these conditions is frequently based on single reports. This patients provider states that the patient has painful and recurrent ovarian cysts. However, there are no peer-reviewed studies in the medical literature specifically evaluating the efficacy of acupuncture in the treatment of ovarian cyst pain. For these reasons, the requested acupuncture therapy has not been shown to be medically necessary for treatment of this patients pain related to ovarian cysts as it is not within the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee has requested chemoembolization for the treatment of his liver cancer. Findings:  The physician reviewer found that chemoembolization is considered a relatively standard treatment for unresectable hepatocellular carcinoma and is endorsed by National Comprehensive Cancer Network Guidelines. Chemoembolization is not curative in this setting, but is used to improve disease control. Typically, if both lobes are involved, the lobes will be treated sequentially. Based upon the evidence provided, the patient was an appropriate candidate for the therapy and its use in this setting was clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old male with a history of respiratory failure and pneumonitis. He is status post VP shut placement and also has a history of chronic hepatic infection. A physical therapy evaluation performed in July 2006 documented a progressive neurological illness, generalized weakness, muscle wasting and impaired breathing. The patient received some physical therapy without documented benefit. His wife is seeking authorization for additional rehabilitation services, which the Health Plan has denied citing a lack of medical necessity for the services.Review of the submitted clinical information indicates the patient is 100% dependent and non-responsive to deep pain stimuli. Based on the records provided, the patient has not made progress with therapy. Furthermore, he is unable to participate in therapy from a cognitive standpoint. He requires positioning and range of motion, which can be performed by trained caregivers. Skilled physical therapy services are not clinically indicated for this patient. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested a magnetic resonance imaging (MRI) for evaluation of his left lower quadrant abdominal pain.  Findings:  The physician reviewer found that this patient has symptoms of left lower quadrant pain following hernia repair with mesh. Also, he has a history of persistently elevated serum alkaline phosphatase. These findings support an indication for imaging. However, the patients provider recommended imaging with CT, which is appropriate. An MRI may be helpful for further evaluation if a CT scan was interpreted as non-diagnostic. Based on the available information, the requested MRI is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).   Findings:  The physician reviewer found that current medical evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The recommendation is again to not deny patients treatment if they have early stage disease: this in fact is an indication to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV.  The medical evidence supports the requested medication in this clinical setting. In sum, the requested medication of Harvoni is medically indicated for this patient.  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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a colonoscopy for evaluation of the enrollee, who has a family history of colon cancer. Findings:  The physician reviewer found that the American Cancer Society guidelines for colon cancer screening state that in patients with colorectal cancer or adenomatous polyps in any first-degree relative before age 60, or in two or more first-degree relatives at any age, the first colonoscopy should be performed at age 40 and subsequent colonoscopies every five years. In this case, this patients sister had adenomatous polyps before age 60. Additionally, the submitted documentation noted both his sister and mother had adenomatous polyps. Based on the information provided for this case, the American Cancer Society guidelines would recommend colonoscopies at five-year intervals in this case, and a screening colonoscopy is overdue at this time. Therefore, the requested colonoscopy is medically necessary for the 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dopamine transporter single-photon emission computed tomography (DaT SPECT) scan. Findings:  Three physician reviewers found that while a DaT SPECT scan is not indicated for all patients with tremor, it has been shown to be useful when the diagnosis of Parkinsons disease versus essential tremor is suspected. These diseases can be challenging to differentiate based only on clinical grounds. In this particular case, the patient reportedly had findings consistent with both disorders. It is imperative to provide a definitive diagnosis, as treatment for Parkinsons disease and essential tremor are quite different, and placing the patient on a trial of therapy would place the patient at risk of significant side effects. In this particular case, the patients care was assisted by the use of this diagnostic study. Therefore, DaT SPECT scan performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in neurology 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 38-year-old female has requested on-going physical therapy (PT) for treatment of a frozen shoulder.  Findings:  The physician reviewer found that the clinical record indicates the patient improved with therapy, but had eventually plateaued. Her shoulder ROM was not within normal range, but was fairly functional. The patients pain did not resolve. It is not likely that additional PT would be of significant benefit at this stage. Continued use of the HEP will help to maintain the gains the patient has achieved and may also facilitate slow improvement in ROM. PT has not alleviated the patients pain and alternative modalities should be explored.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the cooling device (Water Circ Cold pad with pump CPT HCPCS-E0218) for treatment of the enrollees left knee anterior cruciate ligament (ACL) tear and sprain bone injury status post arthroscopic reduction and internal fixation of tibial eminence fracture.  Three physician reviewers found that the continuous flow cryotherapy units provide regulated temperatures through use of power to circulate ice water in the cooling packs. However, the available scientific data are insufficient to establish that the use of continuous flow cooling systems versus ice packs is associated with a benefit beyond convenience and patient compliance. Mechanical circulating units with pumps have not been proven to be more effective than passive hot and cold therapy. All told, the current evidence does not suggest that the cooling device (Water Circ Cold pad with pump CPT HCPCS-E0218) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result:  Three reviewers determined that the device at issue was 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: All three reviewers are board certified in orthopedic surgery 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: The patient has requested reimbursement for all or any of the family psychotherapy services provided. Researchers note that couple-based therapies for posttraumatic stress disorder (PTSD) may be potentially beneficial for reducing symptoms. Family psychotherapy may be helpful as an adjunct to individual psychotherapy for both PTSD and major depressive disorder, generally over 12 to 16 weekly sessions. In this case, the patient has diagnoses of PTSD and major depressive disorder, and attended family psychotherapy from July 2019 through March 2020. Given that the provider recommended and referred the patient for family psychotherapy, the intervention was medically indicated. However, two sessions on the same day are not standard of care and were not medically indicated. Therefore, the family psychotherapy services, one session for each date of service at issue, were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.