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

A 58-year-old female enrollee has requested Euflexxa injections for treatment of her knee osteoarthritis.  Findings:  The physician reviewer found that although some benefit from previous courses of viscosupplementation was noted by the patient, there is inadequate evidence to support another course of treatment with Euflexxa in this case. The efficacy of multiple courses of viscosupplementation in osteoarthritis of the knee is poorly supported in the medical literature. A study by Jorgensen and colleagues indicates, In patients fulfilling the ACR [American College of Rheumatology] criteria for osteoarthritis of the knee with moderate to severe disease activityfive intra-articular injections of hyaluronan did not improve pain, function, paracetamol consumption or other efficacy parameters 3, 6, 9 and 12 months after the treatment. Individuals in this clinical setting are not expected to obtain more than marginal short-term benefit from an additional series of Euflexxa injections. Given the lack of studies evidencing support for the long-term efficacy of the requested injections for the treatment of knee osteoarthritis, the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a chest computed tomography scan. Findings:  Three physician reviewers found that in recent years, there has been intensive studies concerning the merits of a screening program for lung cancer. The most notable and widely accepted study was performed by the National Lung Cancer Screening Team (NLST) a multicenter trial.  Their guidelines were published several years ago and the following patients are considered appropriate for low-dose screening CT scans: the patients should be between 55-74 years of age, have a heavy smoking history, as defined by at least 30 pack per year and either continue to smoke or have stopped smoking within the last 15 years. In the National Comprehensive Cancer Network (NCCN) pamphlet, they have stratified patients into patients at high, moderate, and low risk.  Final Result: Three reviewers determined that the the services at issue were 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 physician reviewers 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 24-year-old male enrollee has requested treatment in a 28-day residential treatment program or partial hospitalization services for treatment of his hallucinogen dependence. Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  There is a lack of support for residential treatment or partial hospitalization program services in this clinical setting.  The medical records do not indicate current suicidal ideation.  Although the documentation notes significant discord in relationships, the patient demonstrated cooperation in treatment and insight into his need for treatment.  The records indicate overall medical stability and no significant psychiatric symptoms.  In this case, current guidelines support intensive outpatient program services.  The records do not document symptoms that necessitate 24-hour residential services or partial hospitalization program services.  Based upon the records submitted for review, treatment in a 28-day residential treatment program is not medically indicated.  Additionally, partial hospitalization program services are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested for a sleeve gastrectomy for treatment of her morbid obesity. Findings:  Two physician reviewers found that many national bariatric programs and Medicare have recognized and accepted sleeve gastrectomy as a legitimate stand alone bariatric procedure. Evidence-based literature has compared sleeve gastrectomy with laparoscopic gastric banding. The literature notes excess weight loss is better with sleeve gastrectomy and the ghrelin factor is absent or negligible. There is also greater improvement in the comorbidities, especially diabetes and hypertension. After sleeve gastrectomy, there is a better feeling of loss of hunger.  Additionally, the late problem of insufficient weight loss is greater after laparoscopic gastric banding.  There is no foreign body present that requires frequent adjustments, and if failure occurs it is much easier to convert to another procedure. A comparison of sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass notes that if failure occurs, conversion is much easier, especially to duodenal switch, since it is already part of that operation.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male has requested speech therapy and occupational therapy services for treatment of his autistic disorder.  Findings:  The physician reviewer found that the scientific literature strongly supports both speech and occupational therapy for the treatment of autistic children. As noted by Myers and Johnson, people with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite sills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers and Johnson). The paper by Turner is a controlled study comparing autistic children who did and did not receive speech therapy.  Those who did receive therapy had far greater communication skills than those who did not undergo speech therapy. The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.There is also strong scientific evidence supporting occupational therapy in autistic children. Pfeiffer et al. reported on an extensive meta-analysis of the literature and concluded that occupational therapy is effective in reducing many autistic mannerisms. Another meta-analysis of 27 journal articles utilizing occupational therapy with sensory integration techniques for autistic children concluded that this modality was effective in this patient population (May-Benson and Koomar).  For the reasons stated above, it is medically necessary that the patient receives both occupational and speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested for Lyrica for treatment of his tarsal tunnel syndrome. Findings:  The physician reviewer found that Lyrica is not FDA approved for tarsal tunnel syndrome, which is a mono-peripheral neuropathy entrapment syndrome. Lyrica is utilized and FDA approved for postherpetic neuralgia, epilepsy/seizures and some neuropathic syndromes that have failed other conservative options. Furthermore, Lyrica has been approved for use in fibromyalgia, but not for widespread pain of unclear etiology that does not meet fibromyalgia diagnostic criteria.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee requested Prolia (denosumab) injections for treatment of her osteopenia.  Findings:  Two physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient is being considered for treatment of osteopenia with the goal of preventing the progression to osteoporosis. She has documented osteopenia on the most recent bone mineral density test with a corresponding fracture risk below the threshold suggested for starting anti-resorptive therapy (Levis and Theodore). Although denosumab is an effective and approved medication for the treatment of both postmenopausal and steroid-induced osteoporosis (Cosman), this patient does not have clinical evidence of either condition. Anti-resorptive therapy is not indicated for the treatment of osteopenia, and has not been studied for osteoporosis prevention. As such, the request for denosumab is not likely to be a more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested blue light cystoscopy with carcinoma in situ (CIS) procedure for treatment of his urothelial carcinoma in situ.  Findings:  Three physician reviewers found that photodynamic diagnosis of nonmuscle-invasive bladder cancer with hexaminolevulinate cystoscopy is unlikely to be more beneficial in the diagnosis and treatment of superficial bladder cancer than traditional cystoscopy and biopsy. The rate of false positive diagnosis is high in patients that have recently been treated with intravesical BCG. In addition, the current American Urological Association (AUA) guidelines do not support the routine use of this technology. Given the lack of scientific data demonstrating superior health outcomes with the requested blue light cystoscopy, 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive care (ICU) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.There is support in the medical literature and the documentation provided for the services at issue in this patients case. The progress notes and the clinical course  met the medical necessity criteria for hospitalization in the ICU.  The patient continued to have frequent neuro checks hourly and concerns for seizure were noted. There was close monitoring of the fluid status and serum sodium, an especially important parameter for postoperative neurosurgical patients. On that date, the patient was getting hourly neuro checks by nursing, was receiving anticonvulsant medications as well as antibiotics. He had drains in place that required monitoring. For these reasons, ICU services were medically necessary for the treatment of this patients medical condition.Findings:The reviewer has determined that the services at issue were 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 medical 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin for treatment of the enrollees short stature with diagnosis of hypopituitarism.Findings: The physician reviewer found that the review of the patients longitudinal growth charts from birth to seven years of age shows that there was deceleration in both length and weight upon shifting from the supine length curve, which is used to plot supine length measurements in children under three years of age, to the standing height curve used to plot standing height measurements in children over three years of age. This may have been due to true discrepancies in measurements between height and length, one or more inaccurate measurements, or true downward channeling that can occur in normally developing children under three years of age that is not due to GH deficiency. The patients height as plotted between ages six to 612 years shows a normal steady trajectory along the 10-25th percentile. Review of prior growth data shows a length at 31 months of age that is at the 25-50th percentile while weight is at the 75th percentile. A measurement plotted at two years six months of age on the standing growth curve is at the 50th percentile. Overall, the records do not demonstrate that there has been recent growth deceleration. This patients growth factors and bone age are normal and there is no evidence of pituitary deficiency. Poor results on provocative GH testing does not alone support a diagnosis of GH deficiency in the absence of evidence of growth failure based on accurate serial growth assessments, pituitary hormone deficiency, or midline brain abnormality. All told, the requested Nutropin AQ NuSpin is not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 53-year-old female who is requesting authorization for a power-operated vehicle (POV). She has a history of knee pain and rheumatoid arthritis. She was evaluated for a POV and was found to be neurologically intact with 5/5 upper extremity strength. The Health Plan has denied authorization of a POV but authorized a manual wheelchair.The Health Plans denial should be upheld. The Health Plan is offering the patient appropriate and medically indicated equipment. The information submitted demonstrates the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. She is neurologically intact and appears to have the upper extremity strength to operate a manual wheelchair. There is no documentation demonstrating the patient cannot operate a manual wheelchair. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested psychiatric intensive outpatient program services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that according to the documentation submitted for review, the patient continues to exhibit agitation and head banging behaviors. In addition, the patients medications are being actively adjusted. The patient has been responding positively overall to interventions, however these will likely need to be skills that are taught to the family to carry forward as the patient transitions to a lower level of care. The study by Vismara and colleagues provided a 12 week, 1 hour per week, individualized parent-child education program to toddlers newly diagnosed with autism. Parents learned to implement naturalistic therapeutic techniques from the Early Start Denver Model, which fuses developmental- and relationship-based approaches with Applied Behavior Analysis into their ongoing family routines and parent-child play activities. Results demonstrated that parents acquired the strategies by the fifth to sixth hour and children demonstrated sustained change and growth in social communication behaviors. Thus, there is support demonstrating that parents of autistic children who have been taught behavioral intervention skills results in lasting behavioral improvements in autistic children. Thus, continued psychiatric intensive outpatient program services are indicated. The time allows for the patient to transition to a lower level of care as he spends more time with family on a daily basis and the utilization of ABA skills at home with the patient.Final Result: The reviewers determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage of botulinum toxin B injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees migraine headaches.Three physician reviewers performed a medical necessity Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is medically necessary for treatment of the enrollee's medical condition. One of the three physician reviewers concluded that the requested therapy is not medically necessary for treatment of the enrollee's medical condition. Because two of the three physician reviewers concluded that the requested therapy is medically necessary for treatment of the enrollee's medical condition, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Ribapak for 24 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated with antiviral therapy regardless of fibrosis score. The guidelines note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The guidelines recommend daily Sovaldi and weight-based ribavirin for 12 weeks for treatment-naive and treatment-experienced patients with hepatitis C, genotype 2 infection. Consistent with current guidelines, a 12-week course of Sovaldi and Ribapak is medically necessary for treatment of the patients medical condition.   Final Result: Two reviewers determined that Sovaldi and Ribapak for 12 weeks is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:  The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A male enrollee requested Harvoni for medical treatment of his hepatitis C genotype 1.  Findings:  Two physician reviewers found that the current guidelines emphasize that those patients most likely to benefit from viral eradication should be treated with direct acting antiviral (DAA) hepatitis C drugs. Most data suggests that patients with advanced fibrosis, severe disease activity, or those with extrahepatic manifestations such as cryoglobulinemia would benefit the most from treatment. For this patient with minimal to no fibrosis, the recommendation would be to follow non-invasive fibrosis parameters serially and consider therapy if there is evidence of histologic progression. Consistent with these findings, the requested Harvoni is not medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Two 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 reviewers are board certified in diagnostic radiology 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 patients parent has requested authorization and coverage for a Dexcom G6 glucose monitoring system. Studies note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. Studies note that while finger-prick devices have commonly been used to monitor blood glucose, continuous glucose monitoring (CGM) systems have recently been refined and improved for home use. Studies report that CGM systems may increase the effectiveness of glucose control and minimize hypoglycemia risk. In a comparison of the Dexcom and FreeStyle Libre CGM systems, Link and colleagues found that the Dexcom G5 Mobile generally appeared to be more accurate in measuring  blood glucose. In this case, the patient has a diagnosis of diabetes mellitus and reports a severe fear of needles. Given that current medical literature supports the use of CGM systems for home monitoring of glucose levels and the accuracy of the Dexcom CGM system, the requested equipment is medically indicated. Therefore, a Dexcom G6 glucose monitoring system is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and metabolism 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.