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

The patient is a five-year-old male diagnosed with autism in November 2004. He has been receiving speech therapy once per week since March 2005. Therapy has focused on repeating 7-word sentences, wh sentences, he/she/they sentences, past tense verbs, his/hers/theirs, and other pronouns. The therapist reports modest gains in therapy. At issue is whether continued speech therapy is medically necessary.The speech therapists documentation of progress toward goals is sufficient evidence that the patient is progressing. It is well documented in speech therapy texts and developmental pediatrics texts that improvement in speech therapy for a diagnosis of autism is measured in years rather than months. Thus, I find the progress shown in this patient and the expected improvements to be reasonable and predictable. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to receive speech therapy once weekly with re-evaluation in six months to verify ongoing improvement.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure at L4-5.Findings:  Two out of three physician reviewers found that the requested Intracept procedure at L4-5 is not likely to be more beneficial than any other available standard treatments for the patients medical condition.The Intracept procedure, or radiofrequency ablation of the basivertebral nerve, is a relatively new procedure. It involves minimally invasively cannulating the pedicles of both vertebral levels of the endplate-disc-endplate complex, targeting the location of the basivertebral nerve, and thermally ablating it with radio-frequency thermal ablation. The procedure is FDA approved and has the following very specific indications: 1) Chronic low back pain (CLBP) of greater than 6 months duration; 2) Failure to respond to other nonsurgical treatments for 6 months; and 3) MRI-demonstrated Modic changes in at least 1 vertebral endplate at 1 or more levels from L3 to S1.In this case, there is no mention in the submitted documentation of dynamic x-rays to rule out obvious instability as a potential pain generator. Records include an MRI that noted the presence of progressive degenerative changes at L3-4 (a level above the requested treatment level) with associated retrolisthesis. If the patient demonstrated clinically relevant dynamic instability on flexion/extension films, the recommended procedure may not be of utility. Modic changes are only identified at one level, with notable degenerative changes at adjacent levels. Under these circumstances, the requested Intracept procedure at L4-5 is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurological surgery 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

A 44-year-old female enrollee has requested for readmission to acute hospitalization for treatment of her non-small cell cancer of the lung, with metastases to the brain, bone, and spinal meninges. Findings:  The physician reviewer found that the medical records indicate that the patient is receiving no intravenous pain medications or any other essential intravenous therapies.  The documentation fails to demonstrate the medical necessity of the requested services.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested hydrocodone/acetaminophen 5-325 mg oral tablets #30 for medical treatment of her chronic pain syndrome, acquired kyphosis, and acquired spondylolisthesis. Findings:  The physician reviewer found that the peer-reviewed medical literature indicates there is a lack of evidence supporting the benefits of opioids for the treatment of chronic pain (Warner). There is no evidence of a recent comprehensive examination having been performed to verify the patient has an ongoing need for an opioid analgesic to treat her symptoms. Moreover, the patient is noted to have had an inconsistent urine drug screen, and there is no evidence of a recent urine drug screen, which is required for ongoing treatment with opioids. Based on the available documentation and the medical literature, the requested hydrocodone/acetaminophen 5-325 mg oral tablets #30 are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old man who has prostate cancer with a PSA of 18 and Gleason score of 6 (3+3). Based upon the information provided, it appears the patient is stage T1c because no disease was palpated. A biopsy of the prostate performed on 10/12/04 revealed no cancer in the left apex; Gleason 6 (3+3) in 30% of specimen of the left mid with 2 of the 4 cores positive; Gleason 6 (3+3) in 11% of specimen of the left base with 1 of the 2 cores positive; Gleason 6 (3+3) in 25% of specimen of the right apex with 1 of 2 cores positive; no cancer in the right mid; and no cancer in the right base. The patients radiation oncologist has recommended the patient undergo intensity modulated radiation therapy (IMRT) because the patients MRI shows a suspicious nodule on the left, and because of the patients obesity, chronic asthma, large volume of cancer, and enlarged prostate. The Health Plan has denied coverage for IMRT and recommends neoadjuvant hormone therapy and 3-D conformal radiation therapy. The patient has stage T1c cancer of the prostate with Gleason 6 (3+3) and a PSA of 18. Based on Partins Tables, there is a 62% chance of cancer being limited to the prostate; a 33% chance of capsular invasion, a 5% chance of seminal vesicle involvement, and a 3% chance of pelvic lymph node involvement. IMRT will deliver 8100 cGy to the prostate. 3-D conformal radiation therapy can deliver 7400-7600 cGy to the prostate. Neoadjuvant hormonal therapy can shrink the cancer and reduce the PSA in 75-80% of prostate cancer, within 2-3 months. There is no evidence the patient will experience a superior clinical outcome with IMRT than with these other therapies. The alternatives offered by the Health Plan are as good if not better than IMRT alone. Thus, use of IMRT in this clinical setting is not medically warranted. Accordingly, 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: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested Celebrex for the treatment of her tendinitis. Findings:  The physician reviewer found that in Rostom and colleagues review of the medical literature they found cyclooxygenase (COX)-2 inhibitors such as Celebrex offered better upper gastrointestinal (GI) safety and were better tolerated with fewer GI symptoms than other NSAIDs. Cullen and colleagues report that adding a proton pump inhibitor (PPI) is also an effective means of preventing gastrointestinal toxicity. Chan and colleagues conducted the only randomized controlled trial comparing a COX-2 with a COX-2 and PPI. The authors concluded that there was a significant decrease in the incidence of recurrent upper GI bleeds with combination treatment. However, these were very high risk patients and the patient would not fall into this category. While the majority of studies have looked at ulcer risk and not this patients symptoms of dyspepsia and reflux, in general, the COX-2 inhibitors have been better tolerated with fewer GI symptoms as reported in multiple studies. Since the patient has continued symptoms which are not controlled on twice a day dosing of Aciphex, it is medically appropriate to treat her with a COX-2 inhibitor such as Celebrex rather than a conventional, non-selective NSAID.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Two physician reviewers found that 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 biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with 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: Upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication Synvisc-One injection to the left knee. The enrollee has a diagnosis of osteoarthritis of the left knee. She has received cortisone injections to both knees. At an office visit six months after a left knee cortisone injection, the physical exam demonstrated moderate vastus medialis obliquus (VMO) atrophy to the left knee. There was no effusion. Range of motion was 0-130 degrees. There was mild lateral joint line tenderness and a normal neurovascular examination. There was a three-quadrant patellar glide with a soft endpoint. Apprehension test was negative, patellar grind test was significantly positive, and Bassetts sign was mildly positive. Due to the enrollees decreased benefit from cortisone injections, her physician recommended Synvisc One injection for the left knee. Documentation notes the x-ray of the left knee revealed no acute osseous abnormality. This enrollees diagnosis is osteoarthritis (OA). Viscosupplementation injections are not recommended for treatment of moderate to severe knee osteoarthritis. Professional society clinical practice guidelines (CPG) for knee OA were released in 2013; revising earlier guidelines of 2008. The revision was based on the systematic review of evidence. The subsequent appropriate use criteria stated the use of viscosupplementation is excluded for non-arthroplasty treatment of knee OA. Studies note the use of preparations such as Synvisc-One is not a beneficial treatment for OA; furthermore, such preparations did not demonstrate significant differences compared to an injection of physiological saline in individuals with knee OA.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 orthopedic sports medicine and orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested artificial disc replacement (cervical disc arthroplasty) for the treatment of his cervical stenosis. Findings:  Three physician reviewers found that there has been a continuing interest in the cervical disc arthroplasty to avoid the possible problems following the present standard, cervical fusion, but questions remain. There is a tendency toward loss of mobility in the operated segments with time, and longer follow-up is recommended to assess functionality over time. Some early studies have shown improvements after arthroplasty, but long-term follow-up is necessary.  The effectiveness of the implants remains uncertain, and there is still a need for prospective, randomized, clinical trials with adequate follow-up to establish the advantages of cervical spine disc replacement over fusion. Overall, artificial disc replacement is not likely to be more efficacious than alternate treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested an ambulatory electroencephalogram (AEEG) for medical evaluation of her post-concussion syndrome and seizure disorder.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested AEEG. In this case, there is a lack of rationale demonstrating the medical necessity for a 72-hour AEEG.  Further, a routine EEG would be adequate to evaluate any seizure disorder that is interfering with ongoing mentation. Finally, an AEEG is generally utilized to determine if someone is having seizures, and not utilized once a seizure disorder is documented. For the reasons provided above, the request for an AEEG is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for adapalene gel (Differin) 0.1% and Aczone 5% for treatment of her acne vulgaris. Findings:  The physician reviewer found that the patient reports having tried and failed therapy with generic tretinoin in the past as it was too drying and clindamycin gel 1%, which lost its effectiveness. Treatment with Aczone 5% is reasonable and considered the logical next step in her acne therapy. The use of Aczone gel 5% has been proven to be effective for the treatment of acne, particularly in adult women. As she has failed treatment with clindamycin gel 1% and doxycycline, the requested Aczone gel 5% is medically necessary. Differin 0.1% has recently been moved to over-the-counter status and is readily available for this patient without a prescription. Final Result: The reviewer determined that a portion of the requested medications is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 33-year-old male enrollee has requested Sovaldi and Ribapak for treatment of his hepatitis C genotype 3A.  Findings:  The physician reviewer found that based on review of the available records, the treatment plan recommended by the provider is medically necessary for treatment of this patients hepatitis C. The available data indicates that the sustained virologic response (SVR) rate is higher for genotype 3 using regimens that contain the direct antiviral agent Sofosbuvir. Further, the American Association for the Study of Liver Diseases (AASLD) recommends a regimen of Sovaldi and ribavirin over interferon based treatment. For these reasons, the requested Sovaldi and Ribapak are supported as medically necessary for treatment of this patients hepatitis C.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair. Findings:  The physician reviewer found that the requested equipment is not medically necessary for treatment of the patients medical condition. The records submitted for review do not include a detailed functional mobility examination. The providers encounter note indicated that she ambulates slowly but without ataxia. There was no documentation of an antalgic gait or lower limb weakness.  There was no documentation of neuromusculoskeletal impairment precluding the use of a gait implement such as a cane or walker, or a manual wheelchair. An individual does not need to raise the upper extremities above shoulder height to propel a manual wheelchair. Moreover, a manual wheelchairs seat height can be lowered so that the feet can be used to assist propulsion without having to bear much weight at all. The patient does not otherwise have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living. In addition, physical activity and exercise are generally appropriate and recommended for conditions such as back pain and for general musculoskeletal health. A power mobility device has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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 FoundationOne gene test. Findings:  Two of the three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic agent would be useful. However, at this time, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized study did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. All told, the superior efficacy of FoundationOne gene test has not been established. 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

A 64-year-old male enrollee requested authorization and coverage of surgery to repair disc disease. The Health Plan  denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees back and neck 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 procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 15-year-old male enrollee has requested neurobiofeedback for treatment of the enrollees attention deficit/hyperactivity disorder.  Findings:  Three physician reviewers found that there is a lack of support for the requested services in this patients case.  There is a paucity of support for the requested services in this clinical setting.  There is a lack of information regarding psychosocial stressors and past interventions such as the specific type, setting and duration of psychotherapy, extent of school-based services or the dosing and length of treatment for psychotropic medications.  Therefore, the requested neurobiofeedback is not likely to be more effective than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Evrysdi. Spinal muscular atrophy (SMA) is an autosomal recessive, inherited genetic disease characterized by degeneration of alpha motor neurons in the spinal cord. Several innovative medications have recently been developed that improve or ameliorate symptoms in many patients. In 2020, the U.S. Food and Drug Administration (FDA) approved Evrysdi for the treatment of SMA in adults and children two months of age and older. Per the FDA, the clinical studies supporting the approval included patients ages two to 25 years of age. In this case, the patient is 30-years-old with a presumed diagnosis of SMA. The records lack formal testing for SMA, although the patients sister has SMA and she presented with similar signs and symptoms. The FDA has approved Evrysdi for the treatment of SMA in adults and children over two years of age. However, this approval was based on studies on patients from two years to 25 years of age. There is a lack of data demonstrating that Evrysdi is safe and effective in patients over 25 years of age. Therefore, the requested Evrysdi is not medically necessary for 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. Credentials/Qualifications: The reviewer is board certified in 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.