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

The patient has requested authorization and coverage for Motegrity 2 mg, 30 tablets for 30 days. Medical literature states that prucalopride treatment relieves symptoms of chronic constipation by targeting the underlying impaired colonic motility; prucalopride is not a disease modifying or curing drug. Researchers reported that prucalopride is effective, has a good safety profile, and is well tolerated for the treatment of men with chronic constipation. In this case, the patient has been diagnosed with diagnosed with CVID associated colitis, gastroparesis and functional abdominal pain/IBS and has failed treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Motegrity 2 mg, 30 tablets for 30 days are medically necessary for the treatment of 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 and allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks, increase in detection of small cancers and improvement in diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old of enrollee has requested weekly for treatment of the enrollees behavioral problems.  Findings: The physician reviewer found that the records provided for review do not support the medical necessity criteria for 75 minute therapy sessions. The patient is a candidate for treatment in a less intrusive, less invasive level of care, and the Health Plans authorization for dialectical behavior therapy (DBT) is reasonable. There is a lack of clinical justification to suggest that 75 minute sessions would result in better improvement in symptoms over standard weekly therapy sessions and routine medication management. Thus, the requested weekly therapy for 75 minutes is not medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the requested services are 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages it brings to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular material from underlying architectural distortion resulting in a decrease in callbacks, increase in diagnostic accuracy and increase in detection of small cancers when compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to the patient than had the exam been done using two-dimensional imaging alone.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 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: Overturned

A 58-year-old female enrollee has requested for the Flector 1.3% patch for treatment of her osteoarthritis and tendonitis.  Findings:  The physician reviewer found that it appears that this patient has significant osteoarthritis in her ankles. Generally, NSAIDs, including topical forms, are indicated for treatment of acute and chronic musculoskeletal inflammatory pain. It is reasonable to prescribe the administration of topical forms of NSAIDs to patients who have gustatory dysfunction. Continuation of oral NSAIDs in patients who experience gastrointestinal (GI) side effects is contraindicated, as these can cause significant pain and discomfort and can be fatal in extreme cases.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested lap-band revision surgery for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient does not meet criteria for repeat or revision bariatric surgery as the records do not document any present complication of the original bariatric procedure that requires surgical repair to correct.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested lap-band revision surgery is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 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 reimbursement for the heart scan (coronary computed tomography angiography (CCTA)) performed. Findings:  The physician reviewer found that based on the records provided the patient has a diagnosis of cardiomyopathy, no documented coronary risk factors and chest pain that is characterized as non-anginal. In this circumstance of no documented coronary risk factors and no documented chest pain that is suspicious for possible coronary ischemia further evaluation with CCTA is not indicated for this purpose and not considered standard of care. Current guidelines endorsed by several national organizations also do not consider CCTA appropriate in this clinical setting. For the reasons provided, the heart scan (CCTA) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne test. Findings:  Two of the three physician reviewers found understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. Although next generation sequencing holds promise, it is not yet ready for routine clinical use. At this time, there is a lack of data demonstrating that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. As a standard of care, biopsies confirming metastatic breast cancer should be tested for estrogen, progesterone, and HER2. It is not documented that this was done on the liver biopsy. All told, FoundationOne test was not likely to have been superior over other available modalities for 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: Experimental/Investigational
Decision: Overturned

The parent of a 20-year-old male enrollee has requested for a PET/CT scan for evaluation of his synovial sarcoma of the left lung. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network states that the requested diagnostic procedure may be useful for prognostication, grading and assessment of response to chemotherapy in patients with soft tissue sarcomas. Volker and colleagues report that this test reveals important additional information and has a relevant impact on therapy planning. PET/CT scans are utilized in the staging and restaging of soft tissue sarcomas, and the outcome of the PET/CT studies does impact treatment planning.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthotics for treatment of the enrollees bilateral foot pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment in this patients case. The records document cavus foot structure with painful metatarsalgia. Orthotics are utilized to correct foot pathology. Numerous pathologies respond well to repositioning the weight-bearing foot with the use of orthotics. In this case, the patient has severe forefoot pain due to a cavus foot structure. Cavus feet tend to be rigid, and these types of foot structures force patients to place a significant amount of pressure to the forefoot, causing pain. Orthotics are utilized to offload significant pressure from the painful area of feet and support the arch and forefoot to allow for pain-free ambulation. The current medical evidence supports the requested equipment in this clinical setting. All told, the requested orthotics are 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 podiatry 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 auditory rehabilitation services once a week. The records provided for review document that this patient presents with hearing impairment status post placement of cochlear implants. The patients provider has recommended auditory rehabilitation services to help the patient achieve functional hearing and avoid development of a long-term communication disorder. Dazert and colleagues reported that, Hearing impairment that is too severe to be adequately treated with conventional hearing aids can lead, in children, to severe developmental disturbances of hearing and language, and, in adults, to communicative and social deprivation. Pediatric cochlear implant patients tend to be delayed in communication skills. Auditory rehabilitation will help close the gap between patients with cochlear implants and those without cochlear implants. Given this support, the requested auditory rehabilitation services once a week are medically necessary for 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 otolaryngology 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 62-year-old female has requested coverage for past radiofrequency neurolysis for treatment of her lumbosacral spondylosis.   Findings:  Two physician reviewers found that the patient has chronic left-sided low back pain that appears to be facet related. The patient has had an anterior or transverse interbody lumbar fusion. According to the provider, the L4-5 and L5-S1 levels are fused but not posteriorly. The provider reports the patient has failed therapy, massage, medication therapy, TENS and acupuncture. The records indicate the patient had over 90% relief for the duration of the local anesthetic block administered and has responded well to the radiofrequency neurolysis. The patient in this case had blocks of the L3-4 and L4-5 facets for posterior element facet mediated lumbar pain after fusion. In many cases, posterior fusion destroys the anatomy of the medial branches and facet joints and fuses them completely. However, anterior and lateral fusions do not destroy the anatomy of the facet joint and often does not completely fuse or remove motion of the posterior elements. As in this patients case, the provider has blocked and ablated the nerves to the facet above the fused levels at L3-4. In addition, the provider ablated the nerves to the L4-5 joint. Given the patients response to medial branch block and the thorough work-up done by the provider, the procedure at issue is in accordance with the standard of care guidelines and interventional pain management guidelines. As this patient had previously failed conservative care and had good response to diagnostic blocks, the procedure at issue was likely to have been more beneficial than any available standard therapy in treating this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested home infusion of intravenous (IV) Invanz for treatment of his diagnosis of Lyme disease.  Findings:  Three physician reviewers found that given the positive plasmid DNA and constellation of symptoms which could be attributable to Lyme, such as tenosynovitis and some of the neurological symptoms, it is reasonable after most other causes have been excluded by conventional medical tests, to treat for neuroborreliosis. The medically accepted treatment in this case would be 28 days of intravenous Rocephin, which this patient received. The Infectious Diseases Society of America (IDSA) guidelines recommend no more than one 28-day course of IV ceftriaxone for late stage Lyme of neuroborreliosis. Evidence that longer courses, or that different antibiotics may be more beneficial, is not available. As outlined in the IDSA guidelines for treating Lyme disease, the expert panel conclusion after examining the data is that over one month of IV therapy for Lyme disease is not more effective than the shorter treatment courses and is therefore not recommended. The continued use of long-term antibiotic for the condition may be more harmful than beneficial. The improvement described in the records is not likely directly related to the long-term continuation of IV antibiotics. For these reasons, the therapy at issue was not and is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested ketamine injections for treatment of his medical condition.  Findings:  Two physician reviewers found that current medical evidence does not support the services at issue in this patients case.  There are many unknowns regarding the antidepressant effect of ketamine, not to mention its risk of treatment-induced hypomania or full-blown mania for those with bipolar disorder.  There is a lack of evidence-informed practice guidelines regarding pre-treatment screening and patient selection criteria, intra-treatment recommended observational metrics, dosing schedules and treatment duration, and post-treatment follow-up.  Finally, the medical documentation does not support the services at issue.  The patient was described as a partial responder to pharmacotherapy.  Previously, he was improved with less anger and irritability.  He reported good benefit from his medications on another occasion.  Further, it does not appear that previously helpful interventions had been exhausted during the episode of illness.  The patient had a therapist, but it is unclear if he had engaged specific evidence-based interventions for bipolar illness, such as cognitive behavioral therapy, family therapy, interpersonal and social rhythm therapy.  All told, ketamine injections were not likely to have been superior over other treatment options.  Final Result: Two reviewers determined that 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 reviewers are board certified in psychiatry 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

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees lymphangioma and speech delay. Findings:  The physician reviewer found that the Rosssetti Infant-Toddler Language Scale administered to this patient at 15 months and 24 months of age indicates that the patient has made no improvement in her language skills over a 9-month period.  Her language development reached a plateau during this period. Speech therapy has been denied based on the lack of diagnosable structural abnormalities in this patients oral pharynx. A review of the records provided indicates that this patient has a congenital dysfunction in the cerebral cortex connecting the frontal and temporal lobes for the generation of speech. Emmanues, et al. states that the clinical decision to provide speech therapy to impaired patients in this patients age group is usually of extreme benefit. A study by Landa indicates that the earlier a patient begins speech therapy, the more likely he or she is to meet developmental milestones. The available peer-reviewed medical literature indicates that speech therapy for children with delays in their language development is beneficial. Given this patients documented deficits coupled with the evidence for the success of speech therapy in this patient population, it is medically necessary that this patient receive individual speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested authorization and coverage of a Positron Emission Tomography (PET) scan of her abdomen and pelvis. The Health Plan denied the request indicating that the requested PET scan is not medically necessary for evaluation of the enrollees metastatic breast cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested PET scan is medically necessary.