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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coenzyme Q10 testing, leptin, cytokine panel, interleukin-6, prothrombin fragment, and matrix metallopeptidase 9 (MMP-9) testing. Findings:  Three physician reviewers found that the current guidelines do not support the services at issue in this patients case. Per the patients provider, these tests were performed to assess nutritional status and make individual lifestyle recommendations. Data gathered largely from observational studies suggest that certain dietary factors may modify breast cancer risk. Of note, methodologic issues regarding the measurement of nutritional intake and the contribution of other factors complicate these analyses and the interpretation of studies. Coenzyme Q10 has been widely promoted for patients undergoing treatment for cancer, based upon the suggestion that it might improve tolerance for chemotherapy. Lesser and colleagues performed a double-blind, placebo-controlled trial in patients with newly diagnosed breast cancer. The authors noted that there was no benefit from the use of coenzyme Q in self-reported cancer treatment-related fatigue. To date, there are no standard testing recommendations or nutritional supplementation that have been shown to decrease the risk of breast cancer. Therefore, coenzyme Q10 testing, leptin, cytokine panel, interleukin-6, prothrombin fragment, and matrix metallopeptidase 9 (MMP-9) testing were not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI) without contrast. The records provided for review document a normal neurological examination including strength and reflexes. The provider recommended a MRI of the lumbar spine to begin the patients work-up. However, the provider also recommended evaluation with an electromyography (EMG), which is not documented in the records provided for review. Further, the patients records report normal neurological examinations. If EMG and serological tests are normal, and the patient still complains of bilateral buttock and right foot paresthesias, the next course of treatment would include a six-week trial of conservative management prior to MRI of the lumbar spine. As noted in the medical literature, MRI of the spine may be indicated to exclude disease entities such as demyelinating disorders, unusual disc disease, or congenital malformations. As noted in the medical literature, MRI of the spine may be indicated to exclude disease entities such as demyelinating disorders, unusual disc disease, or congenital malformations. Based on the available documentation, the patient does not meet the criteria for MRI for the lumbar spine. Therefore, the requested lumbar spine MRI without contrast is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology 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

A 61-year-old female enrollee requested Lyrica 800 mg per day for medical treatment of her fibromyalgia.  Findings:  Three physician reviewers found that the requested medication dosage is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According the manufacturers prescribing information Lyrica is indicated for fibromyalgia with a maximum dose of 450 mg per day. Moreover, current studies and reviews recommend dosing at 450 mg per day. In a randomized, double-blind, placebo-controlled, phase III trial for the monotherapy treatment of pregabalin for patients with fibromyalgia, dosing regimens were evaluated at 300 mg per day, 450 mg per day and 600 mg per day. The authors concluded that at the dosage of 450 mg per day, pregabalin demonstrated improvement in pain score, patient global impression of change, and function.  All told, the requested Lyrica at the dosage of 800 mg per day is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing for evaluation of her medical condition.  Findings: Three physician reviewers found that the  requested gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of sufficient support in the peer-reviewed literature for the genetic testing at issue in this clinical setting. According to Smith In most cases, altered opioid metabolism in older patients, women, or specific ethnic groups can be addressed by careful dose adjustment. In addition, there is a lack of rationale provided for the genetic testing in dispute. Therefore, the gene testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing at issue was 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 physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine in medical 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: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee has requested hypertrophy liposuction for treatment of his gynecomastia.  Findings:  Two physician reviewers found that according to the photographs submitted, the patient has grade III-IV gynecomastia. Hypertrophy liposuction has been requested for treatment of the gynecomastia in addition to resection of glandular tissue. The peer-reviewed literature supports the use of liposuction as an adjunct to gynecomastia surgery to reduce the fibrous breast fat. A study by Hammond states that surgical treatment of gynecomastia is based on the underlying nature of the breast enlargement and ranges from direct surgical excision, to liposuction, to a combination of both, with skin excision performed as needed. In this patients case, the requested hypertrophy liposuction in combination with the approved direct excision is likely to be more effective in addressing both the glandular and fatty tissue. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female has requested speech therapy for treatment of the enrollees mild impairment of speech production skills. Findings:  The physician reviewer found that as noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  When dealing with trauma, speech therapy facilitates return of functional communication. Without intervention, an optimal outcome may not be achieved.  As noted by Turkistani and Hanno, dentoalveolar traumatic injuries result in fractured, displaced, or lost anterior teeth, and this could have significant negative functional, speech, and psychological effects on children.  This patient has articulation delay as a result of dental trauma and necessary delay in prosthesis placement.  The medical evidence supports speech therapy in this clinical situation.  All told, the requested speech therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested OxyContin 40mg every six hours, and oxycodone (IR 30mg twice per day, as needed  not KV Tech brand) for treatment of her neck pain.  Findings :  The physician reviewer found that Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing painful condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is the patients best interest to wean down or off opiates, and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address her chronic pain. High dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  Any opioids as requested by the patient for her chronic pain would be contradictory to providing safe and effective healthcare. The requested medications are therefore not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The father of an 18-year-old male enrollee requested authorization and coverage of the medication Humatrope. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees impaired neurocognitive function.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested Orthovisc injections for treatment of the enrollees osteoarthritis. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more efficacious than other treatment options.  There is a lack of clinical documentation showing evidence of failure to respond to conservative therapy, including exercise, anti-inflammatory medications, acetaminophen or intra-articular steroid injections.  The current medical evidence has not established the superior effectiveness of Orthovisc injections in this clinical setting.  Additionally, as noted by Rutjes and colleagues, viscosupplementation is associated with an increased risk for serious adverse events in patients with knee osteoarthritis.  Therefore, the requested Orthovisc injections are not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Sovaldi 400 mg and Olysio 150 mg for 12 weeks for medical treatment of his chronic hepatitis C genotype 1b. Findings:  Two physician reviewers found that the patient has essentially no fibrosis by non-invasive testing. At this point, this patient has little to gain in treatment of his hepatitis C. His renal failure does not appear to be an extrahepatic manifestation of hepatitis C such as mixed essential cryoglobulinemia. Moreover, there is a lack of information that Olysio and Sovaldi are safe in the setting of this degree of renal insufficiency. For these reasons, the requested Sovaldi 400 mg and Olysio 150 mg for 12 weeks are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance neurography for evaluation of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patients traditional work-up did not offer significant insight into her problems. The requested magnetic resonance neurography is medically appropriate in this case, and the medical records provide a clinical rationale for the requested services.  In sum, the requested magnetic resonance neurography is medically indicated to better elucidate the potential cause of this patients symptoms.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 neurological 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: Medical Necessity
Decision: Upheld

The patient is a 59-year-old woman with symptoms of low energy, aching all over, and difficulty with concentration. She has requested authorization for growth hormone (GH) therapy for presumed adult GH deficiency (AGHD) based on a low IGF-1 and the response to an Arginine/GHRH stimulation test. An MRI of the brain revealed a partially empty sella. The patients provider has recommended the use of growth hormone therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients condition.There is no evidence of AGHD in this patient. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. There is no significant pituitary lesion. Furthermore, partially empty sellas are a common incidental finding on brain imaging studies. The patients endocrinologist has posited no other pituitary trophic hormone deficiency. The patients symptoms are sufficiently non-specific, and GH stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis, unless the clinical context in which the testing is performed is compelling. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the peripheral bone density test (CPT 77081) for medical evaluation of her postmenopausal osteoporosis. Findings:  Two physician reviewers found thatthere is no indication that the spine and hip were not readable on the axial DEXA scan, which fails to produce a clinical indication for the forearm DEXA scan. Accordingly, the peripheral bone density test (CPT 77081) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100-40 mg for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is medically necessary for 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: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of  chemodenervation by botox injections for the treatment of migraine headaches.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that chemodenervation by botox injections are not likely to be more beneficial for treatment of the enrollees migraine headaches than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee requested authorization and coverage of breast reduction surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees breast hypertrophy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the substance abuse residential treatment provided for his alcohol dependence.  Findings:  The physician reviewer found that It appears that the patient underwent detoxification of an indeterminate length. It is unknown what happened between detoxification and his presentation, in a sober state, for residential admission. There are no Clinical Institute of Withdrawal Assessment (CIWA) scores provided for review. His vital signs on admission were stable, and there were no further vital signs in records provided. In addition, there were no physician progress notes or nursing progress notes. Moreover, there were no consistent mental status evaluations. Despite the patient reporting anxiety and depressive symptoms on admission, the patient was not seen by a psychiatrist and not placed on medications.  Overall, the patient was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive factors requiring residential supervision. The patient was motivated, he had sober support, and a safe home environment. He was on Naltrexone and had acquired a sponsor. Given these findings, this patient did not require 24-hour monitoring and could have been treated at IOP level of care, along with AA meetings and the support of his sponsor. Thus, the substance abuse residential treatment provided was not medically necessary for treatment of this patients alcohol dependence.Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee requested authorization and coverage of intravenous Ketamine-infusion therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees foot and leg pain.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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, intensive outpatient program treatment level of care requires a composite score of at least 17.For a CALOCUS composite score of 19, the recommended level of care is intensive outpatient therapy. Therefore, Intensive Outpatient Program (IOP) services were medically necessary for treatment of the patients medical condition.