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

A 77-year-old female enrollee has requested physical therapy services for treatment of the enrollees gait and balance deterioration. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue in this patients case.  The benefits of exercise on health and function in elderly populations are well-established.  In this case, the patient had already undergone physical therapy for her gait and balance symptoms.  The medical records did not indicate that she could not perform an independent exercise program during the dates of service at issue.  Per the submitted records, the patient reported that she was swimming daily and was able to participate in Pilates.  Although she continued to have symptoms, no marginal difference in clinical course or outcomes was expected with ongoing formal therapy over an independent program.  All told, physical therapy services provided from the time frame specified were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Comprehensive genomic profiling test (FoundationOne CDx). As noted in the medical literature, the standard of care for patients with metastatic colon cancer includes testing for KRAS, NRAS, BRAF, HER2, and microsatellite instability (MSI). Per the National Comprehensive Cancer Network (NCCN) guidelines, this testing can be performed individually or as part of next-generation sequencing, which has the ability to detect actionable mutations. The American Society of Clinical Oncology (ASCO) recommends genetic testing on colon cancer tumors. Next-generation sequencing offers the advantage of identifying markers known to have targeted therapy as well as potential clinical trials. Given this patients metastatic disease, comprehensive molecular profiling was appropriate. Accordingly, the comprehensive genomic profiling test (FoundationOne CDx) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the comprehensive genomic profiling test (FoundationOne CDx) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 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 certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Due to the advantages tomosynthesis brings to radiologists in the interpretation of mammograms the American College of Radiology has urged the technique be removed from the investigational category. Tomosynthesis allows the provider to separate dense glandular elements from underlying architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. While there is a lack of long term studies showing an increase in survival rates when tomosynthesis has been added to two-dimensional (2D) imaging, the addition of tomosynthesis was likely of more benefit to the patient than had the mammogram been done with 2D imaging alone. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested intensive outpatient treatment with applied behavioral analysis (ABA) therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that numerous published studies have shown that specific ABA techniques can help patients with autism learn specific skills, such as how to communicate, develop relationships, play, care for themselves, learn in school, succeed at work, and participate fully and productively in family and community activities. Additional peer-reviewed studies have examined the effects of combining multiple ABA techniques into comprehensive, individualized, intensive, early intervention programs for children with autism. To date, ABA is considered by many researchers and clinicians to be the most effective evidence-based therapeutic approach for children with autism. As such, ABA is a medically indicated and necessary modality for the care and management of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male enrollee has requested Lidocaine injections for the treatment of his temporomandibular joint dysfunction/jaw pain. Findings:  The physician reviewer found that there are many physical medicine methods that are recommended for the treatment of myofascial pain. Conservative therapy is generally the first-line treatment and includes use of splints and physical therapy. First-line therapies were not effective for this patient. In select patients, lidocaine injections may be beneficial. The submitted records document that lidocaine was in fact helpful to this patient. Coverage for lidocaine injections is appropriate and necessary for this patients temporomandibular joint pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia services administered during a colonoscopy for evaluation of the enrollees screening colonoscopy. Findings:  The physician reviewer found that this patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in the peer-reviewed medical literature for this clinical setting. Further, the current medical research supports the use of intravenous sedation was appropriate for this patient given his low preoperative physical ASA status classification score.  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 anesthesiology with sub-specialty certification in pain 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

A 45-year-old female enrollee requested authorization and coverage of tattoo removal. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees dermatitis.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: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested DynaSplint for treatment of her temporomandibular joint disorder.  Findings:  The physician reviewer found that arthrocentesis of this patients TMJ is an indicated option for the treatment of her condition. The standard for post-operative care may include the use of oral appliance therapy and physiotherapy in the form of jaw opening exercises. Jaw exercises may include initial light active range of motion stretching with advancement to active and passive stretching including lateral movements. Although a DynaSplint may facilitate these physiotherapy maneuvers, it is not routine for every patient undergoing arthrocentesis. In this patients case, there is no documentation of any barriers for the performance of standard physiotherapy exercises. Therefore, the requested DynaSplint is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested the medication Nuvigil for medical treatment of her multiple sclerosis-related fatigue. Findings:  Two physician reviewers found that although Nuvigil is not considered a first-line therapy for fatigue in multiple sclerosis, there is support for the requested medication in this clinical setting.  The patient reported that Nuvigil has been beneficial.  She is unable to take more standard medications due to prior adverse effects.  Undertreated fatigue can potentially cause significant morbidity.  All told, the requested medication Nuvigil is likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee requested weekly individual psychotherapy, monthly psychiatry medication management appointments, full panel hormone testing, testing for Addisons disease, and testing for adrenal gland dysfunction for medical treatment of her depression and anxiety.  Findings:  The physician reviewer found that the records indicate the patients current medication regimen is not yet controlling symptoms and she continues to require ongoing regular psychotherapy visits. Weekly psychotherapy is appropriate to treat the patients condition, consistent with standards of good medical practice in the United States and is thus medically necessary. In addition, medications need to be prescribed by a psychiatrist, which supports the request for monthly psychiatric visits for medication management. However, it is not medically necessary to perform full hormone panel testing, testing for Addisons disease, or additional adrenal gland dysfunction testing based on the records provided for review.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested continued use of Arimidex 1mg for the treatment of the enrollees Russell Silver syndrome. Findings:  The physician reviewer found that a 2009 study by Dunkel indicates that Arimidex increases adult height potential of adolescent boys on growth hormone therapy while maintaining normal pubertal progression after two to three years. Treatment with an aromatase inhibitor such as Arimidex offers an alternative in promoting growth in GH deficient boys in puberty. As the patients provider indicates, Arimidex will allow the patients puberty to progress while protecting him from increased sensitivity to the effects of estrogens. The use of Arimidex in this setting is well supported by the medical literature.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a four-year-old female enrollee requested authorization and coverage of continued private speech therapy for the treatment of developmental delay.  The health plan denied the enrollees request indicating that the requested speech therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested speech therapy is medically necessary if a new Functional Communication Measure (FCM) evaluation details that the enrollee has made progress since the last FCM evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old man with a long history of bruxism and facial pain. He is currently being treated with a dental occlusal splint. Botox injections into the masseter muscle were added to his treatment regimen and the patient reported subjective improvement in bruxism and pain. A request has been made for reimbursement and continued authorization and coverage for Botox injections. The Health Plan has denied this request on the basis that Botox therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Botox injections into the muscles of mastication to control bruxism is not within the standard care. Botox has not been approved by the Food and Drug Administration for treatment of temporomandibular joint dysfunction and bruxism or myofascial pain syndrome. Furthermore, review of the medical literature does not reveal sufficient evidence that Botox is efficacious in this clinical setting. Therefore, I have determined that the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 3-year-old male enrollee has requested Up N Go Gait Trainer and adaptive car seat for treatment of the enrollees spastic paraplegia.  Findings:  The physician reviewer found that from a review of the available records, the requested Up N Go gait trainer appears to be primarily a piece of therapeutic equipment for the patient. However, the documentation does not demonstrate that he can use the equipment functionally to improve his activities of daily living or that he can use it functionally within the community. For these reasons, the Up N Go gait trainer has not been shown to be medically necessary at this time. With regard to the adaptive car seat, given the patients age, there should be a standard car seat that provides adequate trunk support with a 5-point harness restraint. The medical literature is sparse in terms of guidelines on selecting car seats for children with special healthcare needs. The California Childrens Services (CCS) guidelines require the patient to be 4-years-old and 40 pounds with poor head and trunk support in order to qualify for an adaptive car seat. Thus, while this patient may benefit from an adaptive car seat in the future, it would currently not be considered medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections for the right knee every six months.Findings:  Two of the three physician reviewers found that the current medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Per the medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. In this case, the patient has been diagnosed with osteoarthritis of the right knee with supportive clinical examination findings. He has been treated with Synvisc One injections to the right knee every six months for the past year. He has reportedly achieved pain reduction and ability to reduce his anti-inflammatory medication use with the injections. There is support for one Synvisc One injection for the treatment of his right knee osteoarthritis. Thus, one Synvisc One injection for the right knee is likely to be more efficacious than other treatment options. At this time, there is a lack of support for ongoing injections every six months, as the need for continued services should be established based on the ongoing response to these injections. Final Result: The reviewers determined that a portion of the requested services 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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

A 63-year-old male enrollee requested authorization and coverage of a Helios oxygen system. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees cardiac problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 73-year-old female enrollee has requested for Xifaxan for treatment of her small intestinal bacterial overgrowth. Findings:  The physician reviewer found that results of clinical trials demonstrate that the reduction or elimination of SIBO with antibiotics can alleviate IBS symptoms. The systemic antibiotic neomycin has been evaluated in two clinical studies by Pimentel and colleagues. The non-absorbed oral antibiotic rifaximin is the most thoroughly studied antibiotic for the treatment of IBS. The efficacy of rifaximin in the treatment of IBS was evaluated in a randomized, double-blind, placebo-controlled, parallel-group study of 87 patients who met Rome I criteria for IBS, and it was found to be beneficial in terms of substantial improvement of global symptoms. Long-term therapeutic benefits of rifaximin were also observed in two studies that assessed the effects of rifaximin on other functional gastrointestinal symptoms. However, long-term prospective studies are needed comparing various antibiotics including quinolones, metronidazole, neomycin, tetracycline and rifaximin in the patients with SIBO before any conclusions can be drawn about the superiority of rifaximin over other antibiotics.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested radiowave/laser vein surgery (endovenous surgery) for treatment of his foot ulcers.  Findings:  Three physician reviewers found that endovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing.  Recent evidence suggests that perforator ablation is successful in promoting recurrent ulceration. Current guidelines recommend compression therapy as the primary treatment to aid healing of venous ulceration, which this patient has undergone for several years. To decrease the recurrence of venous ulcers, ablation of the incompetent superficial veins in addition to compression therapy is also recommended in the guidelines. Although selective treatment of perforating vein incompetence in patients with simple varicose veins is not recommended, it is suggested that patients with pathologic perforating veins located underneath healed or active ulcers receive treatment. Given, the above guidelines and available peer reviewed medical literature, the requested procedure is likely to be more beneficial for treatment of this patients ulcers than conservative management.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested an MRI of the breast for evaluation of her lobular carcinoma in situ.  Findings:  Two physician reviewers found that this patient has a history of biopsy-proven lobular carcinoma in situ in the left breast and an abnormal area of enhancement in the right breast. Of note, lobular cancer is known to become bilateral in at least 25% of proven cases. Coupled with the difficulty in mammographic and sonographic detection of lobular cancer versus the more common invasive ductal cancer, MRI has been increasingly used as a diagnostic tool, especially when breast tissue has been described as mammographically dense.  Considering the diagnosis already proven on the contralateral side, close surveillance is required using MRI in this patients case. All told, an MRI of the breast is likely to be the most efficacious method of evaluating this patient.