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

Nature of Statutory Criteria/Case Summary: A parent of a five-year-old male enrollee has requested authorization and coverage for referral to cranial sacral osteopathy for treatment of the enrollees bilateral esotropia and hyperopia. Findings:  The physician reviewer found that there is currently a lack of peer-reviewed medical literature to support the beneficial effects of craniosacral therapy, especially on patients with ocular disorders. Clinical trials have failed to produce evidence of changes in coronal suture movement or intracranial pressure with craniosacral manipulation. Moreover, studies have attempted to evaluate examiner reliability for palpation of the cranial rhythmic impulse and concluded it was poor to nonexistent. Overall, there is a lack of evidence based studies to suggest that craniosacral therapy would improve this patients hyperopia or esotropia. Thus, the requested cranial sacral osteopathy is not supported as medically necessary for treatment of this patients medical condition. 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 osteopathy and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage of an RS Medical Stimulator for the treatment of cervical discogenic spine pain and myofascial pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that an RS Medical Stimulator is not likely to be more beneficial for treatment of the enrollees cervical discogenic spine pain and myofascial pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old man has multiple pigmented skin lesions, at least some of which are on his abdomen and right arm. The patient has requested that his moles be evaluated by a dermatologist. The Health Plan denied this request indicating that evaluation and treatment by a dermatologist is not medically necessary because the patient can be sufficiently treated by his primary care physician.Generally, dermatologists are better qualified and more knowledgeable and experienced in treating skin cancers and evaluating possible skin cancers. Though the Health Plan indicates that evaluation and treatment of dermatologic disorders, as well as skin surveillance for skin cancer, are within the scope of practice and clinical expectation of a primary care physician, there is no evidence of peer-reviewed studies supporting this contention. Consultation with a dermatologist for evaluation of the patients moles is medically reasonable and indicated. If the dermatologist determines excision/biopsy is appropriate, the Health Plan should provide authorization for these services to be performed by the dermatologist. Therefore, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for distal tibial allograft (fresh) procedure. Findings:  Three physician reviewers found that according to a study of consecutive patients with a minimum 15% anterior glenoid bone loss, patients had recurrent anterior shoulder instability which was treated with fresh distal tibia allograft glenoid reconstruction. Twenty-seven patients were followed up to 45 months. The healing rate was 89% and there were no cases of recurrent instability. The authors concluded that the use of distal tibia allograft reconstruction for recurrent anterior shoulder instability results in a clinically stable joint with excellent clinical outcomes and minimal graft resorption. The study assessed the clinical and radiological outcomes after osteochondral allograft reconstruction for glenoid bone loss. The level IV data suggests that allograft reconstruction for glenoid loss provides excellent clinical outcomes, no rates of recurrent instability, and high osseous incorporation rates with no evidence of graft resorption. In light of the foregoing, the requested procedure of distal tibia allograft reconstruction of the glenoid for recurrent anterior shoulder instability is medically appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested procedure 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: All three physician reviewers are board certified in orthopedic 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

Nature of Statutory Criteria/Case Summary:    An enrollee has requested Orenitram for treatment of his pulmonary arterial hypertension.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There are numerous medications that are approved by the U.S. Food and Drug Administration (FDA) for the treatment of patients with primary pulmonary hypertension, including Letairis, Opsumit and Tracleer.  The Health Plan has denied coverage for Orenitram and reported that there are preferred drugs such as Letairis which the patient has not tried first.  The Health Plan is within standard of care to require a trial of one of its preferred drugs for the treatment of pulmonary hypertension.  There is no documentation that the requested medication Orenitram is superior with respect to the long-term health outcome to other FDA approved medications (or combination of medications) to treat primary pulmonary hypertension.  All told, the requested medication Orenitram is not medically indicated 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.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease 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 parent of an enrollee has requested Tobii I-15 communication device including accessories for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that for people living with damage to their corticospinal and corticobulbar tracts, or spinal muscular atrophy, the use of assistive technology such as eye tracking, has been of significant benefit.  As a result of this technology, the person with no ability to create voluntary speech can become fluent and communicate again.  The programs that assist artificial generation of speech are sophisticated enough to convey the information conveyed in normal speech, including accurate representation of phonemes and diphones as well as prosody.  This represents the standard of medical care for this patient.  All told, the requested Tobii I-15 communication device including accessories is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 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

The patient is a 64-year-old male with multiple myeloma and diabetes. He has a several year history of a whole body dysesthesia, which he describes as itching, but also has characteristics of pins and needles. He tried Neurontin up to 800 mg twice daily with only slight improvement. He was recently tried on Lyrica with moderate improvement at 150 mg twice daily, but more substantial improvement at 200 mg twice daily. At issue is whether a dosage of Lyrica 200 mg twice daily is medically necessary for the patients condition.Lyrica has been shown to be safe at doses of 300 mg twice daily. In dealing with painful neuropathy, patients experience a vast difference in response to medication due to metabolic and genetic factors. Some patients respond better to higher doses. Since this patient has shown a better response to Lyrica 200 mg twice daily without significant adverse effects, and safety has been shown in doses up to 300 mg twice daily, the requested prescription is medically reasonable and appropriate and should be authorized. Therefore, I have determined the requested prescription is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has received lasting benefit from prior viscosupplementation with Euflexxa. Furthermore, his remaining treatment options are limited. The patient has tried and failed other conservative treatments including physical therapy and medication, with the alternative being bilateral total knee arthroplasties. For these reasons, the requested Euflexxa injections in both knees 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 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prostatic urethral lift (PUL) procedure for treatment of the enrollees benign prostatic hyperplasia (BPH) with nocturia. Findings:  Two physician reviewers found that the Urolift procedure has been approved by the U.S. Food and Drug Administration (FDA) as an effective treatment of appropriately selected patients with benign prostatic hyperplasia. The Urolift procedure has been shown to be successful and safe in short-term outcomes. However, this patient has had a modified TURP. Therefore, the indications for Urolift procedure are not known. Further, this patient has had persistent symptoms of irritation along with obstructive symptoms and increased residual urine. Thus, an urodynamic study would have been appropriate to confirm bladder outlet obstruction including pressure flow studies, prior to repeat transurethral surgery. Since the records do not document that an urodynamic study was performed prior to the Urolift procedure, the PUL procedure performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the procedure at issue was 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 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 reimbursement for the cell free fetal DNA gene testing for evaluation of the enrollees risk for having a fetus with genetic disorders.Findings:  Three physician reviewers found that there are multiple options for aneuploidy screening including cell-free DNA. The American College of Obstetricians and Gynecologists (ACOG) practice bulletin states that, women should be offered the option of aneuploidy screening or diagnostic testing for fetal genetic disorders, regardless of maternal age. Thus, the use of basic aneuploidy screening is considered within the standard of care. However, there are no recommendations to routine screening for fetal sex chromosome aneuploidies. Final Result: All three reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in obstetrics and gynecology 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: An enrollee has requested Dexilant 60 mg, two times per day for treatment of the enrollees gastroesophageal reflux disease.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication dosage.  Dexilant, unlike other proton pump inhibitors, is released in an extended fashion.  This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors.  The use of Dexilant 60 mg, twice daily is associated with severe adverse effects including hypertension.  Dexilant 60 mg, once daily is supported by current medical literature, but Dexilant 60 mg, twice daily is not.  In patients with scleroderma, who are at higher risk for reflux, twice daily proton pump inhibitor is supported by literature.  However, if twice-daily proton pumps inhibitor is needed, other proton pump inhibitors can be given twice daily, but Dexilant twice daily is not supported.  For these reasons, Dexilant 60 mg, two times per day is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication dosage is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld 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 22-year-old female enrollee has requested bilateral lumbar sympathectomy for the treatment of her hyperhidrosis. Findings:  The physician reviewer found that an article by Reisfeld and colleagues, which was submitted with this appeal, reports the results of 1312 patients with hyperhydrosis treated with endoscopic thoracic sympathectomy. However, the requested procedure is a lumbar sympathectomy, rather than a thoracic sympathectomy. A literature search of lumbar sympathectomy for the treatment of plantar hyperhydrosis reveals additional articles regarding the requested procedure. In 2007, Rieger and Pedevilla performed bilateral lumbar sympathectomies on 8 patients. They concluded that in all cases, pedal sweat secretion was completely suspended post-operatively. After a 3- to 8-month follow-up period, the anhidrosis persisted in all cases (100%). Five patients (62%) reportedly experienced minor compensatory sweating of the torso, and four patients (50%) had post-sympathectomy neuralgia. Thus, while the procedure appeared to be effective, there was a significant complication rate. Furthermore, the report was of low quality; used a small number of patients; involved a short period of follow-up; and lacked randomization or controls. The same group subsequently published a larger series (Rieger and Pedevilla 2009). This study involved 90 patients (59 men, 31 women) with severe plantar hyperhidrosis. Follow-up examination was carried out for all patients after a mean follow-up of 24 (with a range of 3-45 months) months. While all of the patients had evidence of postoperative sympathetic denervation of the feet, compensatory sweating occurred in 40 patients (44%) and post-sympathectomy neuralgia occurred in 38 patients (42%). While the authors concluded that endoscopic lumbar sympathectomy was a safe and effective option for patients with severe plantar hyperhidrosis, this study was retrospective nature, involved a relatively short period of follow-up, and lacked randomization or controls. Loureiro and colleagues performed a randomized study in which 30 female patients with persistent plantar hyperhidrosis were enrolled. During the immediate post-operative period, 3 patients (20%) experienced prolonged pain (more than 10 days). Eight patients experienced worsened compensatory sweating (53.3%). The authors concluded that although endoscopic retroperitoneal lumbar sympathectomy diminished plantar sweating in women with plantar hyperhidrosis, about half of the patients develop increased compensatory hyperhidrosis in other areas of the body. All told, the efficacy and safety of lumbar sympathectomy for this indication has not been sufficiently established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mammogram and a breast magnetic resonance imaging (MRI) every 6 months for evaluation of the enrollees risk for breast cancer.  Findings:  Two physician reviewers found that the patient has a strong family history of breast cancer in her sister who was diagnosed with invasive ductal breast cancer at the age of 30. The patient has had prior mammograms and breast MRI studies that have shown extremely dense breast tissue. BRCA testing was negative. The patient had a screening breast MRI on and is requesting reimbursement for this study as well as future coverage for a mammogram and breast MRI every 6 months. The American Cancer Society (ACS) does not advocate for screening breast MRI for patients with dense breast tissue. Review of the peer-reviewed medical literature did not find an exact formula or risk factor for patients with this patient's heritage. Using the Breast Cancer Risk Assessment Tool (also known as the Gail model) this patients lifetime risk for developing breast cancer is approximately 17.6% including the patients positive family history of breast cancer in her sister. It is well documented in the medical literature that a yearly screening breast MRI is medically appropriate for patients with a calculated life time risk of greater than 20%. The American Society of Breast Surgeons recommends breast MRI, [a]s part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA 1 or 2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. At this time, there is insufficient clinical evidence to support the use of screening breast MRI in this patient. This is primarily because the patients calculated risk of developing breast cancer is less than 20%. For these reasons, breast MRI and mammogram are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy at the requested frequency.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with heterogeneously or extremely dense tissue.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Three 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.