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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing and counseling. Findings:  Two of the three physician reviewers found OncotypeDx is a 21 gene analysis of an individuals breast cancer cells. It is particularly useful in predicting prognosis as well as the utility of adjuvant chemotherapy in HER2 negative, estrogen receptor positive, node negative breast cancer. In such patients, it is standard of care for making the decision about adjuvant chemotherapy. Generally, oncologists are using the results of OncotypeDx assay on a case by case basis, particularly if the nodal involvement is minimal, as in this patients case. There is data that the test is useful and reliable in node positive cancer. This patient, with minimal nodal disease, who might otherwise automatically receive chemotherapy, would benefit from OncotypeDx assay. Therefore, genetic testing and counseling was likely to have been more efficacious than other methods of evaluating this patient.Final Result: The 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: 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

A 20-year-old female enrollee has requested psychiatric intensive outpatient program services for treatment of her bipolar I disorder and polysubstance dependence.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  In this patients case, the records note polysubstance dependence and bipolar disorder, a serious mental illness that elevates suicide risk and is consistent with poor outcomes.  She presented with debilitating depressive symptoms, including anxiousness and had relapsed despite recently completing a rehabilitation program.  The patient was enduring significant dysfunction across multiple domains of functioning.  She was unable to garner positive therapeutic momentum in the outpatient setting.  However, the patient was motivated for sobriety.  Per the medical records, the patient has been active in treatment but has not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The current medical evidence supports the services at issue in this clinical setting.  In sum, considering the peer-reviewed literature and current practice guidelines, psychiatric intensive outpatient program services from the date indicated and forward were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a positron emission tomography (PET) scan with fluciclovine F-18. PET with computed tomography (CT) attenuation is a valuable imaging modality in evaluating patients with prostate cancer. Findings: the physician reviewer found that the primary role for PET is the restaging of patients with biochemical recurrence after radical prostatectomy or external beam radiotherapy. Gleason score and PSA values, doubling time, and velocity can influence the positivity of PET. Fluciclovine PET has a high positivity rate (PR) for detection of prostate cancer recurrence and correlates with increasing PSA levels. For extraprostatic disease, the PR increases with higher Gleason scores. Savir-Baruch and colleagues noted that, fluciclovine PET/CT has a high PR for detection of prostate cancer recurrence and is positively correlated with increasing PSA levels. Therefore, the requested PET scan with fluciclovine F-18 is medically necessary for evaluation of this patient.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 diagnostic 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: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested Nuvigil 250mg for treatment of his depression complicated by chronic insomnia.  Findings:  The physician reviewer found that in this case, the submitted documentation demonstrates the medical necessity of Nuvigil 250mg.  The medical records document that the patient uses a CPAP, and the patient reported fatigue and poor quality sleep.  The patients treating physician has indicated that Nuvigil is requested for sedation related to chronic insomnia secondary to depression.  American Psychiatric Association guidelines indicate that there is evidence to support stimulants as an adjunct in treating depression.  The requested medication is medically necessary for this patients condition according to current evidence-based practice standards and expert consensus.  All told, the requested Nuvigil 250mg is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for hydrocodone-acetaminophen (ten 10-325 mg tablets, one to two tablets every six hours. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the records note chronic pain involving multiple sites related to a history of TMJ, lumbar radiculopathy, and a mechanical fall causing broken toes. The records document a history of previous opioid use disorder and the patients providers, including pain management providers, have not recommended or prescribed narcotic therapy. Given that this patient is being treated in a manner consistent with current medical literature regarding opioid therapy for non-cancer indications, the requested medication is not medically indicated. Therefore, hydrocodone-acetaminophen (ten 10-325 mg tablets, one to two tablets every six hours, are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuropsychological evaluation services (CPT codes 96132 x 2, 96133 x 2, and 96137 x 1) provided by Massachusetts General Physicians Organization, Inc. In the management of children with autism spectrum disorder (ASD), Hyman and colleagues do not  suggest neuropsychological testing for the ongoing care of patients with ASD. In clinical practice guidelines for the assessment and treatment of children with anxiety disorders, Walter and colleagues do not list an indication for a neuropsychological evaluation. In this case, the patient underwent initial neuropsychological testing in February 2018. The patient has diagnoses of ASD and anxiety, and a history of tics. The records did not document concerns regarding a deterioration in cognitive ability. Given the lack of support in current medical literature for neuropsychological testing in the management of children with ASD and anxiety, the services at issue were not medically indicated. Therefore, neuropsychological evaluation services (CPT codes 96132 x 2, 96133 x 2, and 96137 x 1) provided by Massachusetts General Physicians Organization, Inc. were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Multaq for treatment of his paroxysmal atrial flutter.  Findings: The physician reviewer found that the request for Multaq has been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient has paroxysmal atrial flutter that has been refractory to ablation, cardioversions and trials of multiple medications. The documentation supports that all classes of antiarrhythmic medications have been tried and failed. In this clinical setting, Multaq is medically reasonable and appropriate. In addition, current guidelines support the use of Multaq in this setting (January, et al). Therefore, the requested medication is medically necessary for treatment of the patients medical condition.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 cardiovascular diseaseand 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: Am enrollee has requested reimbursement for real-time remote heart monitor (CardioNet monitor).Findings:  Two physician reviewers found that there is a lack of support for the device at issue in this clinical setting.  In this circumstance, if evaluation for dysrhythmias is thought to be indicated, then Holter monitoring for frequent symptoms or off-line self-activated event monitoring for less frequent symptoms should be sufficient in recording cardiac rhythm during palpitations.  In addition, off-line auto-triggered event recorders should be effective in identifying asymptomatic paroxysmal dysrhythmias.  There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed.  Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias.  The medical evidence does not support continuous real-time monitoring by telemetry services in this case, since off-line analysis of a patient-activated or auto-triggered event recorder should be sufficient in the identification of dysrhythmias without jeopardizing patient safety.  Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services was not indicated, and has not been shown to improve health outcome compared to standard monitoring techniques. Final Result: Two reviewers determined that the device 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 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: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested endoscopic resection of the pineal lesion via a supracerebellar approach for medical treatment of the enrollees pineal lesion.  Findings:  The physician reviewer found that the current medical literature does not support an advantage of endoscopic removal of the pineal lesion as compared to the standard approach of suboccipital craniotomy with a supracerebellar approach.  The medical evidence does not support a demonstrable benefit of one procedure as opposed to another.  Thus, endoscopic resection of the pineal gland is not medically necessary over the standard approach of a suboccipital supracerebellar craniotomy.  All told, the requested endoscopic resection of the pineal lesion via a supracerebellar approach is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested for PET scan for evaluation of his diffuse fibrosis of the peritoneum, retroperitoneum and pituitary gland.   Findings:  Two physician reviewers found that PET scans have been shown to be clinically relevant for certain cancer diagnosis (including melanoma, lymphoma, NSCLC and colorectal cancer) and to evaluate solitary pulmonary nodules. The use of PET scans for retroperitoneal fibrosis is not universally accepted. Some institutions have utilized PET scans to differentiate between malignant and benign retroperitoneal fibrosis. This patient has biopsy-proven benign retroperitoneal fibrosis. There are also anecdotal cases of false positive PET scans in patients with retroperitoneal fibrosis. At this time, the use of PET scan for retroperitoneal fibrosis is experimental and investigational.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services provided. The records indicate that the patient experienced behavioral health conditions. The patient was not a danger to himself or others, nor did he engage in self-harm. There were no emotional, behavioral, or cognitive issues to warrant RTC level, nor was he manic or psychotic. He was psychiatrically stable, and his other medications did not require RTC level of care for management. His vital signs were stable and he was noted to be cooperative and an engaged participant in the recovery process. Although remaining a risk for relapse due to impaired insight and judgment, the issues he was working on in therapy could have been addressed in an ambulatory setting. The records indicate that the patient could have continued his recovery treatment on an ambulatory level of care, with community support in a 12 step programs and working with a sponsor and counselor. All told, the RTC services provided were not medically necessary for treatment of this patients behavioral health condition. 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Cologuard testing. A gastroenterology note indicates the enrollee had an acute episode of gastroenteritis. Her physician explained screening options available, indicating the most accurate test is colonoscopy. Other options presented were fecal immunochemical test (FIT) screen, Cologuard, CT colonoscopy and colonoscopy.  Findings:  The physician reviewer found that guidelines for colorectal cancer screening indicate patients fifty years or older with no history of predisposing conditions or family history for colorectal cancer may be screened using colonoscopy, stool-based testing, immunochemical-based testing or DNA-based testing; flexible sigmoidoscopy, or computerized tomography (CT) colonography. Cologuard should be used in adults aged fifty older who are at average risk for colorectal cancer.  This patient is at average risk for colon cancer.  She does not meet the age criteria for the use of Cologuard testing.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested for a cooling device and combined cooling/heating device for treatment of his post-surgical pain and swelling. Findings:  The physician reviewer found that the literature does not demonstrate any significant benefit of cryotherapy or pneumatic cooling devices over standard intermittent ice pack cold treatment for postoperative recovery following rotator cuff repair surgery. Furthermore, there is no evidence that such devices lead to improved outcomes in the mid and long terms.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old female enrollee has requested authorization and coverage for Genotropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patient does not meet standard criteria for growth hormone deficiency, as her pre-treatment height is not more than 2.25 standard deviations below normal for age and sex, bone age is normal, IGF-1 level is normal, results of provocative growth hormone testing are normal, and she has no known morphological abnormalities of her pituitary gland.  Per current guidelines, a trial of growth hormone therapy may be indicated for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations below the mid-parental height percentile, bone age more than 2 standard deviations below the mean for age, low serum IGF-1 and/or IGFBP-3, and/or other clinical features suggestive of growth hormone deficiency.  Based upon these guidelines, the requested growth hormone therapy is not indicated in this patients case.  Although the patient is reported to have demonstrated an increase in growth velocity after initiation of growth hormone therapy, no information on pubertal status is provided, and it is unclear whether other factors may have played a role in the patients improved growth.  No follow-up bone age report was provided to assess whether the adult height prediction has changed after the initiation of growth hormone therapy.  All told, Genotropin is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee requested authorization and coverage for a referral to an orthopedist.  The health plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees arm and hand pain.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for additional chiropractic visits for treatment of her back pain. Findings:  The physician reviewer found that no clinically significant benefit with respect to analgesic, health, or functional outcomes is expected with further chiropractic therapy, based on the available clinical data.  There is a lack of proven benefit of chiropractic treatment in the setting of scoliosis, chronic low back pain, chronic hip pain, complex regional pain syndrome, or other musculoskeletal conditions.  No significant marginal benefit would be expected over independently applied palliative modalities, such as thermal modalities or self-massage techniques.  The medical records do not support any specific, clinically relevant benefit that has been achieved which can be objectively attributed to the chiropractic treatment provided to date. All told, the requested additional chiropractic visits are not medically necessary in this clinical setting.