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

A 53-year-old female enrollee requested a computed tomography (CT) scan of the chest (thorax without dye, 71250) for medical evaluation of the enrollees medical condition.   Findings:  Two physician reviewers found thatthe services were not likely to be more effective for this patient than other available options. Although patients with earlier stages of lung cancer have an improved survival, studies comparing populations of patients who received screening with sputum cytology and chest x-rays revealed no improvement in survival over those patients who did not receive screening. The study performed by the International Early Lung Cancer Action Program Investigators screened 31,567 asymptomatic persons at risk for lung cancer using low-dose CT. The study found that screening resulted in a diagnosis of lung cancer in 484 participants. However this study did not have a control group. Thus, it has not been documented that routine screening improves survival. Although in this case the patient has a history of smoking, the medical records submitted for review did not document hemoptysis, productive cough or chest pain. Therefore, the CT scan of the chest is not standard of care and not likely to be more beneficial for evaluation than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1b. Findings:  The physician reviewer found that 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 non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested for inpatient rehabilitation treatment for treatment of her bulimia nervosa and polysubstance dependence.  Findings:  The physician reviewer found that Fairburn and colleagues describe the effectiveness of cognitive-behavioral therapy for patients with eating disorders including a more complex treatment modality that also addresses mood, self esteem and interpersonal difficulties.  Crow and Petersons article mentions the benefit of cognitive behavioral therapy (CBT) particularly for bulimia nervosa. American Psychiatric Association practice guidelines note that treatment for eating disorders includes a range of services, such as intense outpatient or partial hospitalization. Hospitalization is usually indicated if there is a rapid or persistent decline in oral intake, medical instability or severe co-occurring psychiatric disorders that merit hospitalization.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested Synvisc/Orthovisc injections for treatment of his patellofemoral osteoarthritis. Findings:  The physician reviewer found that it is not medically necessary for this patient to receive hyaluronan injections as proposed by the provider. There are carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injections in this clinical setting. In addition, there is a documented incidence of aseptic inflammatory reactions due to allergic response as well as a low but present risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit, and that there is an increased risk of serious adverse effects. Overall, the requested viscosupplementation with Synvisc is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer status post significant benign breast surgery.   Findings:  Two physician reviewers found that the patient has no personal or family history of breast or ovarian cancer. She has documented extremely dense breast tissue on mammography. Fourteen years ago, the patient underwent excisional biopsy of microcalcifications. The surgery was complicated, and on an examination four years later, the provider noted that secondary to extensive scarring in the left breast, and very dense breast, mammography was limited. Since that time, the patient has had screening magnetic resonance imaging (MRI) exams in lieu of mammography, with the most recent performed four years ago. As noted by the American Cancer Society (ACS), breast MRI has clinical indication in a patient with a defined high risk of developing breast cancer, a patient newly diagnosed with breast cancer, to evaluate the extent of disease, and for assessment of disease after treatment. The ACS states that, problem-solving breast MRI rarely identifies otherwise occult cancer and can be falsely negative in patients with suspicious findings on mammogram and US. This patients surgery was more than ten years ago. Therefore, it would be appropriate to have a mammogram and ultrasound first, to determine if there are increasing calcifications, which may not be seen on MRI. Mammography, in conjunction with ultrasound and physical examination would be appropriate for this patient, and in fact may detect changes that would be missed on breast MRI. Breast MRI is not shown to be an effective screening test alone. All told, the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard modality.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested for a magnetic resonance angiography (MRA) of the head, MRA of the neck and magnetic resonance imaging (MRI) of the brain for evaluation of her headache, seizure and facial paraesthesia. Findings:  The physician reviewer found that MR imaging of the brain should be considered as the study of choice in evaluating patients with demyelinating disease since computed tomography (CT) scanning will not be able to show multiple sclerosis (MS) plaques with reliability, even after intravenous (IV) contrast administration. It is not, however, the choice for imaging an acute ischemic attacks, unless other techniques such as diffusion weight imaging are applied. Imaging of the intra/extracranial vasculature could be achieved with CT angiography and/or ultrasound. However, CT angiography adds the risk of ionizing radiation exposure as well as reaction to the injected contrast. Ultrasound, even though valuable for imaging of carotid circulation, may be limited in the evaluation of the posterior/vertebrobasilar system. In both cases, MRA is very valuable using a two dimensional time of flight technique without requiring the use of contrast. It provides excellent visualization of the blood vessels and may be able to detect areas of stenosis and other abnormalities such as arteriovenous malformations and aneurysms.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement and prospective authorization and coverage for Venclexta (venetoclax) 200 mg daily. A phase 1 study of Venclexta monotherapy in 66 patients with relapsed or refractory multiple myeloma with an average of five prior lines of therapy, reported an overall response rate in 21% of patients. In addition, the response rate was higher among the patients with t(11;14) genetic abnormality when compared with non-t(11;14) patients. The U.S. Food and Drug Administration (FDA) placed a hold on this study until adjustments, including the administration of prophylactic antibiotics, were instituted. Overall, Venclexta monotherapy exhibited an acceptable safety profile and evidence of single-agent activity in patients with heavily pre-treated relapsed or refractory multiple myeloma, predominantly in patients with t(11;14) abnormality. This patient has aggressive disease that carries the t(11:14) mutation. Therefore, Venclexta (venetoclax) 200 mg daily was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found Venclexta (venetoclax) 200 mg daily, was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the medication at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate artery embolization (PAE) procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional). The first-line therapy for management of benign prostatic hyperplasia (BPH) includes medical therapy. This includes alpha-blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors and anticholinergic medications. The standard of care for management of patients with BPH not responding to medical therapy is transurethral resection of the prostate (TURP). In patients with glands over 100 cc, as this patient, holmium laser enucleation of the prostate (HoLEP) and prostatectomy are recommended. Prostate artery embolization (PAE) is a novel approach for treatment of patients with BPH. Current medical literature on PAE is limited to case series and retrospective comparisons. There is a lack of randomized controlled clinical trials demonstrating the improved efficacy of PAE over TURP, HoLEP or simple prostatectomy. The medical literature does not support use of PAE over standard treatments. All told, the requested PAE procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional) are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PAE procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional) are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in urology 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

The parent of an 8-year-old female has requested approval for 10 hours per week of applied behavioral analysis (ABA) therapy and 8 hours per month of supervision for treatment of her autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Granpeesheh, et al). Evidence-based studies also have demonstrated improvement of function in older children with autism spectrum disorders using intensive ABA interventions. The goals for older children often are to identify and remediate particular deficits. Treatments based on operant principles of learning were noted to be more effective for reducing problem behaviors displayed by individuals with intellectual disabilities and autism than were alternative treatments (Grey and Hastings). In addition to this patients maladaptive behaviors of communication, noncompliance, and screaming, her social and language skills should be addressed in an effort to increase her functional life skills. ABA therapy is a necessary and appropriate modality to address these concerns.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old male enrollee has requested authorization and coverage for a cervical artificial disc replacement procedure (CPT code 22856) at the C5-6 level for treatment of the enrollees C5-6 disc herniation. Findings:  Three physician reviewers found that the patient has a history of neck pain and left shoulder pain. He has experienced some numbness and weakness in his left hand. He has been evaluated by neurological surgeons and physical examinations revealed negative Spurlings tests, no motor, sensory, nor reflex deficits and normal reflexes. His imaging studies have demonstrated anterolisthesis at C3-4 and disc osteophyte complexes at C4-5 and C5-6 with more significant stenosis at the C5-6 level on the left. The patients provider has discussed surgical options with the patient, including anterior decompression and fusion at the C5-6 level and artificial disc replacement at the C5-6 level. The patient has requested authorization for a cervical artificial disc replacement procedure at the C5-6 level. There is no data available in the peer-reviewed medical literature demonstrating the long-term safety and efficacy of the artificial disc replacement procedures utilizing the ProDisc C. Although there are a number of published reports which indicate artificial disc replacement with the ProDisc C is promising, these studies are small in scale and of short duration. A study by the Food and Drug Administration (FDA) to determine the long-term safety and efficacy of the ProDisc C is still ongoing and results have not been published. Therefore, there is inadequate evidence demonstrating that the requested procedure is likely to result in a better clinical outcome for this patient as compared to standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested continuous glucose monitoring for the treatment of her diabetes. Findings:  Two physician reviewers found that the majority of insulin pump patients use the available CGM systems episodically in order to change their insulin prescription because they have not reached their glycemic goal, or are having unexplained hypo- or hyperglycemia. This is particularly important for patients who have hypoglycemia unawareness. We do not know if this is a problem for this patient.  In most situations, several 72 or more hour readings may be needed several times a year.  The Health Plan is apparently willing to cover the cost of the CGM up to two times a year if the patient meets its criteria. More frequent continuous glucose monitoring would not be warranted for most patients. This patient does not need to be on the system for her entire lifetime.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a panniculectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested surgery. In this case, the patient presents with significant weight loss following bariatric surgery and as a result of this weight loss, she has excess skin of the lower abdomen that is well-documented to be associated with chronic rashes, skin irritation and significant malodor.  She has been prescribed dermatologic treatment without resolution. Although the size of her abdominal pannus is not severe, based on the overall clinical documentation from multiple providers, the patient has a typical pattern of chronic dermatologic insult associated with excess skin-to-skin contact. Chronic rashes are a functional deficit and its non-surgical treatment has failed. The requested panniculectomy is medically necessary for this patient as it would likely directly address this functional deficit. According to the medical literature The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms. This is the case for this patient and thus, panniculectomy is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery 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 plastic and reconstructive 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: Overturned

A 59-year-old female enrollee has requested Provigil for treatment of her depression.  Findings:  Two physician reviewers found that provigil is indicated for augmentation of treatment for major depression as it has been shown most useful to treat the adverse side effects of selective serotonin reuptake inhibitors (SSRIs) particularly sedation and impaired concentration as well as cognitive impairment. In addition, her successful use for over four years makes it contraindicated to discontinue and would risk worsening her clinical condition. For these reasons, the requested medication is likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies
Appeal type: Experimental/Investigational
Decision: Upheld

A 61 year-old male enrollee requested authorization and coverage of lung volume reduction surgery for the treatment of emphysema.  The health plan denied the enrollees request indicating that the requested surgery is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that the lung volume reduction surgery is not likely to be more beneficial for treatment of the enrollees emphysema 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Foundation molecular panel testing. Findings:  Two of the three physician reviewers found Individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. The National Comprehensive Cancer Network guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Molecular profiling is now considered a standard of care in patients with recurrent or persistent ovarian cancer. The medical evidence supports the requested services in this clinical setting. In sum, Foundation molecular panel testing is likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: 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: Overturned

Nature of Statutory Criteria/Case Summary: A represented minor male has requested authorization and coverage for three speech therapy sessions. Findings:  The physician reviewer found that based on the available documentation, the requested speech therapy is medically necessary to address this patients significant pragmatic language disorder due to his autism spectrum disorder. The patient continues to have difficulty engaging in and sustaining conversations. Notes suggest that the resulting difficulties include inappropriate interactions with peers, the stereotyped use of language, and the employment of nonverbal communication. Studies emphasized the importance and benefit of a multimodal therapy approach to children on the autism spectrum who have impaired pragmatic language. The studies reported that speech therapy, social skills groups, and peer engagement were beneficial. All told, the requested three speech therapy sessions are medically necessary for treatment of this patients medical condition. 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.