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

A 42-year-old male enrollee has requested a computed tomography (CT) heart scan for an evaluation of his medical condition. Findings:  Three physician reviewers found that this patient is a relatively young male who has no cardiac symptoms and only one documented cardiac risk factor of modest hyperlipidemia (LDL less than 160). In this setting, the patients 10-year risk for developing significant coronary stenosis is low based on Framingham scoring. In this low risk circumstance, guidelines for evaluation and management of hyperlipidemia have been developed, endorsed by several national organizations, and do not include routine screening with coronary calcium scoring using CT. In addition, appropriateness guidelines for coronary CT imaging have also been developed, endorsed by several national organizations, and do not consider quantification of coronary calcium appropriate in a general population of asymptomatic individuals with low coronary heart disease risk. There is no study to support that a change in treatment based on results of coronary calcium quantification in this group of patients leads to an incremental outcome improvement above that obtainable by treatment based on standard risk factor profiling.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the LINX procedure for the treatment of his medical condition.   Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The current data indicate that patients experience fewer symptoms after surgery, have improved pH profiles, and use proton pump inhibitor (PPI) therapy less often.  However, the device has not undergone rigorous study with controlled trials.  To date, there is a lack of trials comparing LINX to more traditional reflux operations such as fundoplication. Additionally, it has not been compared to standard medical therapy longitudinally.  All told, the requested LINX procedure is not likely to be of greater benefit than other treatment options.  Final Result: Three 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:  All 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara injections every 4 weeks.Findings: Current medical literature supports dose escalation of Stelara every four weeks in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. A study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications. In another study, dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Additionally, multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has failed alternative medications (such as Remicade and Humira), and required budesonide to control disease symptoms while on Stelara every 8 weeks. The patients tested Stelara level was unlikely to be sufficient to control Crohns disease. Continued use of Stelara every eight weeks or a change to another medication may result in worsening disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization or need for surgery. Therefore, the requested Stelara injections every 4 weeks are medically necessary for treatment of the patients medical condition.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the gene testing (Foundation One) for evaluation of the enrollees oligodendroglioma.  Findings:  The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. The National Comprehensive Cancer Network (NCCN) guidelines have not determined that molecular markers are useful in treatment determination (predictive markers) and prognosis other than codeletion of 1p and 19q, isocitrate dehydrogenase 1 and 2 (IDH1 and IDH2) mutation, and MGMT promoter methylation. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. In this clinical setting, testing that included codeletion of 1p and 19q, IDH1 and IDH2 mutation and MGMT promoter methylation was indicated for this patient. Thus, a portion of the gene testing (Foundation One) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of three reviewers determined that a portion of the testing 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 partially overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

The parent of an 11-year-old male has requested combined outpatient psychotherapy and medication management for treatment of his autism, attention deficit hyperactivity disorder (ADHD) and Tourettes syndrome. Findings:  The physician reviewer found that psychotherapy is unusual in children, and is especially difficult to administer successfully in a child who functions at the verbal and behavioral levels.  This directive and supportive guidance, at a frequency of a weekly visit, is excessive and is not medically necessary. The Tenex, a beta-blocker, is appropriate for treatment of the tics, and may also modulate the symptoms of the patients ADHD. The Focalin therapy has not been altered in a year and does not require weekly monitoring, as ADHD patients on established psychostimulants are usually followed at three month intervals. All told, none of the peer-reviewed literature indicates a need for weekly pharmacological follow-up of medications in the treatment of ADHD, Tourettes syndrome or autism.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees knee pain.Findings:There is sufficient support in the medical literature for the requested services in this clinical setting. Studies concluded that hyaluronic acid is an effective pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Studies conducted a systematic review of overlapping meta-analyses (total 20,049 patients) comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. This patient presents with a history of persistent right knee pain and limited functional mobility. Clinical examination findings are consistent with radiographic evidence of moderate medial and patellofemoral compartment joint space narrowing and spurring. He has undergone multiple corticosteroid injections with inadequate relief of symptoms. Therefore, Synvisc injections have been demonstrated as medically necessary for treatment of the patients medical condition.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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other alternatives.  There is a lack of support for the bilateral breast tomosynthesis in this clinical setting.  The medical records do not indicate an increased risk of breast cancer.  Although breast tomosynthesis is a promising technique, the superior efficacy of bilateral breast tomosynthesis has not been established.  Final Result: Two 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:  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 parent of the enrollee is requesting authorization and coverage for speech therapy. The enrollee was screened for developmental problems. An assessment showed a mild delay in expressive language and a moderate delay in receptive language. The enrollee has been receiving speech therapy and is making progress. Documentation also states he is showing increased engagement. According to the medical literature, a diagnosis of developmental deficit in a child indicates an abnormal state of function, and speech, language, and hearing services are as medically necessary for this enrollee as they are for an adult who has suffered a stroke and has lost speech and language function. Speech language therapy is the best method to treat developmental expressive language disorder. The goal of speech therapy is to increase the number of phrases a child can use. Based on the improvement noted by his speech therapist and the active involvement of the enrollees family in his therapy efforts, speech therapy two times per week is medically necessary. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric rehabilitation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopically assisted vaginal hysterectomy (LAVH). Findings:  The physician reviewer found that a hysterectomy is appropriate for pelvic pain after a comprehensive evaluation has been performed, including evaluation by pain specialist and mental health evaluation, as indicated. Furthermore, if investigations have not identified specific etiology of symptoms, individuals are encouraged to undergo uterine sparing treatments, hormonal treatment, or utilize gonadotropin releasing analogues, analgesics, antidepressants, and physical therapy.  In the case of endometriosis, a hysterectomy is appropriate when the endometriosis has been confirmed by histology, laparoscopic visualization, or identification of endometrioma.  the patient has been diagnosed with endometriosis as the cause of her pelvic pain.  However, the records do not support that this patient has exhausted conservative management options. Progestins such as oral progestins (norethindrone acetate and dienogest), Depo-Provera (intramuscular progesterone), and levonorgestrel intrauterine devices have been shown to be effective at treating pain associated with endometriosis. Gonadotropin releasing hormone agonists with add back therapy have also been shown to be effective at treating pain associated with endometriosis. For women with pain and endometriosis, suppression of menstrual cycles with gonadotrophin-releasing hormone (GnRH) analogues, the levonorgestrel-releasing intrauterine system (LNG-IUD) and danazol were beneficial interventions. There was no evidence of benefit with post-surgical medical treatment.Both the American College of Obstetrics and Gynecology and the American Society for Reproductive Medicine recommend hysterectomy as a treatment option for endometriosis only for patients who have completed childbearing and who have failed conservative surgical and medical management. The records provided do not indicate that this patient meets the recommended criteria for hysterectomy. The patient is 33 years of age and has not failed medical management. She has not tried either progesterone therapy or gonadotropin releasing hormone agonist therapy. Additionally, there is no documentation of uterine sparing surgical measures. Per the current guidelines by professional societies, this patient has not failed all conservative therapies. Therefore, LAVH has not been demonstrated as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for PCA3/KLK3 antigen test for evaluation of the enrollee, who has a history of elevated prostate specific antigen (PSA).  Findings:  The physician reviewers found the clinical utility of this test is uncertain, as there is a lack of evidence that the use of PCA3 antigen test can be used to change management in ways that improves outcomes. PCA3 is a gene that has been found to be highly overexpressed in prostate cancer. It is one of the most prostate cancer-specific genes identified, with over-expression in about 95% of cancers tested. The PCA3 urine assay uses transcription-mediated amplification to quantify PCA3 in prostate cells found in urine samples. The main target population of this non-invasive test is men with concerns about prostate cancer (raised/rising PSA, abnormal exam) after a prior negative prostate biopsy. However, these studies are preliminary and lack standardization in their reports on clinical performance and interpretation of PCA3 results. Based on the available evidence, the overall certainty of clinical validity to predict the diagnosis of prostate cancer using PCA3 is deemed low. Therefore, the PCA3/KLK3 antigen test was not likely to have been more efficacious than other standard modalities in evaluating this patient. Final Result: All three 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 reviewers number one, two, and three are board certified in urology 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: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested a continuous positive airway pressure (CPAP) machine and related supplies for the treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that based on the results of the patients polysomnogram, a diagnosis of sleep apnea is not supported. An AHI of 2.2 events/hour is within the normal range which is 0.0 to 5.0 events/hour. Although the patients provider references the patients respiratory disturbance index, this measurement is not generally used to support a diagnosis of sleep apnea. Furthermore, this patient has several co-morbidities which could be contributing to her excessive somnolence and sleep disturbance. All told, a CPAP device is not indicated for this patient because there is inadequate evidence of obstructive sleep apnea based on the records provided.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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 surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for twice a week one and one half hour psychotherapy sessions.In this case, the patient has a history of trauma, depression, anxiety, dissociative identity disorder, and autism spectrum disorder spanning decades. The submitted documentation reflects that the patient has made progress over almost 30 years of treatment which has included inpatient stays, outpatient therapy, and medication management. Treatment is likely to be an ongoing necessity for the patient, however, based on her presenting concerns. Based on the provider's treatment plan, there is evidence that progress has been made since treatment began, and there are clearly outlined goals describing what will be addressed during the requested one and one half hour sessions twice a week. Given the expertise of the treating provider, it would be in the patient's best interest to continue to receive psychotherapy, as there is a dearth of expertise on dissociative identity disorder. The requested intensity of services is in line with what is recommended in treatment guidelines, and it does not appear that the requested services or intensity are at the convenience of either the patient or the provider, and outpatient psychotherapy is one of the least intensive settings in which service can be provided. Accordingly, the requested twice a week one and one half hour psychotherapy sessions are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed psychologist who is a board certified behavior analyst 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.