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

A 55-year-old male enrollee has requested coverage for stereotactic body radiotherapy (SBRT) for treatment of the enrollees prostate cancer. Findings:  Three physician reviewers found that the patient presented with an elevated prostate specific antigen (PSA) of 7. A transrectal ultrasound (TRUS) revealed a 23cc prostate volume and a needle biopsy revealed involvement in eight of 12 cores of the prostate with adenocarcinoma Gleason score 3+3=6. Clinically, he was staged as T1C. He had a computed tomography (CT) of the abdomen and pelvis, as well as a bone scan, revealing no evidence of metastases. The patient has requested authorization and coverage for stereotactic body radiotherapy (SBRT) with CyberKnife, which the Health Plan has denied as investigational. The management of low risk prostate cancer can include surgery, external beam radiation using intensity modulated radiation therapy (IMRT) or brachytherapy. The use of SBRT is currently undergoing clinical evaluation. Data from King and colleagues reveal a low risk of late rectal and bladder injury. However, the authors concluded that, Continued pursuit of SBRT for prostate cancer is warranted--but with reasonable cautionbecause longer follow-up will be necessary to confirm durable biochemical control rates and continued low rates of late toxicities. The authors concluded that, Enrolling patients on carefully designed SBRT clinical trials is indicated at this time. Currently, there is a paucity of data to support SBRT with or without CyberKnife technology as more beneficial than standard accepted treatments in caring for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested panniculectomy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical documentation does not support that the patient has evidence of a significantly overlapping abdominal pannus.  The photographs do not show evidence of a significantly overhanging abdominal pannus that would be addressed with a panniculectomy.  He does not have a well-defined functional deficit that would likely be treated with a panniculectomy.  Although the records note chronic back pain, abdominal examination and submitted photographs do not provide evidence that a panniculectomy would likely improve his condition.  Therefore, the requested panniculectomy is not medically indicated for the treatment of this patient.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 plastic 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: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested intravenous immunoglobulin (IVIG) therapy for the treatment of her hypogammaglobulinemia. Findings:  The physician reviewer found that monthly infusions of IVIG are medically necessary for this patient. Laboratory records indicate the patients base immunoglobulin levels are low. IgA and IgM are absent. This is a significant finding, indicative of hypogammaglobulinemia. When the patients IgG level was measured after missing IVIG treatments for at least two months, IgG was low at 640 (normal 700-1500). This finding, in combination with absent IgA and IgM, indicates hypogammaglobulinemia. As the patients provider points out, the fact that the patient had normal IgG levels while under treatment does not mean that she has normal immunoglobulins. The reason for the frequent testing of levels is to confirm that the IVIG replacement therapy is adequate. A normal level is expected with adequate therapy. As noted above, when the patient was not receiving therapy, her IgG level fell to below normal.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 8-year, 11-month-old male has requested speech therapy,occupational therapy, and speech consultation for treatment of his autism.  Findings:  The physician reviewer found that the publication from Turner and colleagues is a controlled study comparing autistic patients who received speech therapy against patients who were untreated. Those who did receive therapy had far greater communication skills than those who did not receive speech therapy. The report of the Speech and Language Association, states that all autistic children can benefit from speech therapy. Pfeiffer and colleagues reported on an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the unwanted mannerisms associated with autism. In addition, May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing OT with sensory integration techniques for autistic children. However, the requested speech consultation has not been established as medically necessary as the patients needs and parental training should be adequately addressed during the  ST to be provided.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nerve block. Findings:  The physician reviewer found that the request for nerve block is not medically necessary for treatment of the patients medical condition. There is a lack of medical literature supporting the requested service in this clinical setting. A study reported that sympathetic blocks may be medically useful for diagnostic and treatment considerations of peripheral neuropathy with findings of sympathetic mediated pain. In the absence of sympathetic pain symptoms or physical findings, sympathetic nerve blocks are not beneficial. The medical records submitted for review fail to demonstrate findings of sympathetic pain. There is no indication of hyperpathia, peripheral skin changes, hair growth abnormalities or temperature changes consistent with sympathetic mediated pain. As the records do not indicate such findings, a nerve block is not supported as medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 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

The parent of a 22-month-old female enrollee requested bilateral reverse last shoes  open toe (custom orthopedic shoes for medical treatment of the enrollees bilateral metatarsus adductus.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  There is a lack of support for the requested custom orthopedic shoes in this clinical setting.  The medical literature has shown that shoe therapy may produce a negative impact on future foot posture in patients.  Williams and colleagues noted there was strong evidence supporting no treatment in the case of flexible metatarsus adductus.  The medical literature has shown that most cases of metatarsus adductus resolve spontaneously and without treatment.  Therefore, the requested custom orthopedic shoes are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested prostate cancer antigen 3 (PCA3) testing for treatment of his elevated prostate specific antigen (PSA).  Findings:  Three physician reviewers found that the PCA3 testing performed was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Clinical studies have not demonstrated that PCA3 testing is sufficiently accurate to diagnose or exclude the presence of prostate cancer. If clinically indicated, saturation biopsy is likely to be more useful if prior biopsies are negative. Given the lack of scientific evidence demonstrating the clinical utility of the disputed testing as well as the availability of proven alternative methods of detection in this setting, there is inadequate support for the use of PCA3 testing. As such, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a seventeen year-old female with previously Cannabis Abuse and ADHD are requesting authorization for inpatient drug rehabilitation services.Reviewers Findings:The reviewing physician found that the patient appeared to be suffering from a very significant Major Depression in addition to ADHD, and was treated properly for both during inpatient treatment.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL pen injector. Findings:  The physician reviewer found that the medical literature showed that Repatha is an effective alternative to patients that have statin intolerance or cannot take statin such as this case. According to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, this patient is already on maximum high intensity statin therapy with atorvastatin 80 mg and she has not achieved 50% reduction. Moreover, the patient has coronary artery disease so it is important to decrease her LDL-C beyond current levels and this can be done by adding Repatha to her regimen. Furthermore, the patient must stop statin therapy due to hepatitis, therefore Repatha is a safe non-statin alternative to decrease LDL-C. 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 endocrinology, diabetes, and metabolism 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

An enrollee has requested authorization and coverage for thoracic spine magnetic resonance imaging (MRI) without contrast. The decision to obtain specialized cross-sectional imaging of the spine involves multiple considerations. While pain is a common and significant complaint, not everyone who has pain needs a computed tomography (CT) scan or magnetic resonance imaging (MRI). As a fundamental principle, an imaging study is only necessary if it will affect the management of the patient. In this case, given the patients negative thoracic spine x-ray, the likelihood of detecting a significant abnormality following MRI that would change the management of the patient is minimal. As has been shown in multiple studies, incidental finding of degenerative disease or disc abnormality are exceedingly common in asymptomatic individuals. Some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. In this case, the patient has no symptoms other than pain, which she reports having had for at least five years. There is no evidence of radiculopathy, prior tumor, or infection. While it is always possible that random testing of any organ will demonstrate a significant finding, the likelihood is slim. It has been noted that a diagnosis of type III Ehlers-Danlos Syndrome (EDS) has been considered for the patient. EDS is, for the most part, a clinical diagnosis. While there are genetic tests available to make a diagnosis of EDS, these are not readily available. There are no clearly diagnostic imaging tests to confirm this diagnosis, and a thoracic spine MRI would not be helpful. Under these circumstances, the requested thoracic spine magnetic resonance imaging (MRI) without contrast is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld

A 55-year-old female enrollee requested authorization and coverage of the medication Vioxx for the treatment of arthritis.  The health plan denied the enrollees request indicating that Vioxx is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a total right knee replacement for the treatment of her right knee pain. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that all conservative treatment options have been exhausted by this patient. More intensive physical therapy, a home exercise program, additional weight loss, change in nonsteroidal anti-inflammatory drugs (NSAIDs) and viscosupplementation are all possible therapies that have yet to be adequately trialed. Further, there is no evidence of advanced joint disease necessitating total knee replacement surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Integra for treatment of her finger injury. Findings:  Two physician reviewers found that the evidence based literature supports the use of Integra in this patients case. Integra is in the category of a xenograft tissue coverage material with collagen processed from both bovine collagen and a shark collagen. Contraindications include hypersensitivity to bovine collage, chondroitin or silicone. In this clinical setting, there is no documentation of hypersensitivity or allergic reaction to this material. The use of Integra is likely to be beneficial in providing immediate coverage of the amputation site and is likely to limit the formation of a scar. The studies have shown that this process tends to bring nerve ending sensible skin over a larger portion of the fingertip minimizing the area of sensory deficit in the long finger. Maximizing the area of retained sensibility in the fingertip is best assured by the use of Integra, a xenograft material, as an intermediate dressing prior to a decision to either allow healing by secondary intention or autograft from donor site. Additionally, there are studies that indicate that infection and fluid loss from the tissue are likely to be minimized by the use of Integra. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 reimbursement for the gene test (Panorama screening testing). Findings: Two of the three physician reviewers found that there is sufficient support for the services at issue in this patients case. Noninvasive prenatal screening by cell-free DNA testing is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening and does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, the gene test (Panorama screening testing) was likely to have been of greater benefit 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 reviewer one, is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer two is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer three is board certified in clinical cytogenetics and genomics and is actively practicing. All 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for continuation of care at an inpatient hospital facility. The records provided for review document that this patient was treated with oral anticoagulation for deep vein thrombosis (DVT), wound care with dressing changes for leg wound, and oral antibiotics. The patient has not required any additional care to support an indication for continued inpatient hospital stay services. The provider reported that the patient has improved, is afebrile, and on oral medication. Based on the peer-reviewed medical literature, the patients treatment regimen as planned is appropriate, and there is a lack of indication for requested inpatient hospital services. Therefore, the requested continuation of care at an inpatient hospital facility is not medically necessary for treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for intensive outpatient program services received. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The Health Plan noted that the patient had improved with treatment and was not in a state of distress. However, it is important to conceptualize IOP placement as a programmatic episode of care, as opposed to daily units of service. Further, studies suggest improved functionality and decreased mortality associated with individuals who complete intensive outpatient programming. In this case, the patients positive presentation on was the result of the treatment course as a whole including its targeted end date. Despite anxiety and a positive tetrahydrocannabinol drug screen, both of which were suggestive of the need for on-going treatment, the patient was consolidating the treatment experience and solidifying aftercare plans, which were particularly imperative as the patient had a long history of poor self-esteem, rejection sensitivity and need for validation. At the time, this summation of care and preparation for discharge was both important and appropriate clinical activity for an IOP program. This clinical setting was safe and consistent with good medical practice in the United States, while the services were reasonably expected to facilitate a smooth transition to the outpatient setting. Further, the duration of services were aligned with community practice standards. As such, intensive outpatient program services received was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry 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.