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

A 32-year-old female enrollee has requested OB nuchal translucency ultrasound, blood test and consultation for an evaluation of her pregnancy. Findings:  Three physician reviewers found that nuchal translucency testing is becoming the standard of care and has been recommended by the American College of Obstetrics and Gynecologists (ACOG) as a screening test for all pregnant women. According to the ACOG, the goal is to offer screening tests with high detection rates and low false positive rates that also provide patients with diagnostic testing options if the screening test indicates that the patient is at an increased risk for having a child with Down syndrome.  Thus, the use of nuchal translucency testing in this case was consistent with generally accepted standards of practice and was likely to be more beneficial than the alternative of not performing the screening.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested Lyrica for treatment of her pudendal nerve entrapment. Findings:  Two physician reviewers found that the literature details anti-convulsant membrane stabilizer medications as being the first line therapy in the standard of care for peripheral neuropathy and neuropathic pain caused by many factors. The Health Plan is denying coverage for the medication Lyrica because the patients neuropathy is not caused directly by post-herpetic, or diabetic nerve irritation. However, neuropathic pain is mediated by peripheral C-and A-delta fiber excitation; the nerve affected and the underlying cause are not of clinical significance.  Lyrica has good bioavailability and is an excellent anti-neuropathic pain agent. As a membrane stabilizer, it works well in the periphery and decreases nerve polarization and abnormal action potentials that evoke pain responses. The submitted evidence demonstrates that the patient has done well with Lyrica, has not had any deleterious side effects and is on a moderate dose. She continues to work and be productive, and has failed many other therapies to treat this refractory pudendal neuralgia.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees expressive language delays. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial.  As noted by Law and colleagues, children with speech and language difficulties which persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  This patient is a bilingual child with significant delays in receptive and expressive speech/language skills that negatively impact his ability to express his needs and interact with peers and adults. Objective testing initially demonstrated language comprehension at the nine-month to 12-month level and language expression at the six-month to nine-month level. The literature supports therapeutic intervention for children such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested the Colon Sentry test for evaluation of her risk of colorectal cancer.  Findings:  Three physician reviewers found that the Colon Sentry test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of data in the peer-reviewed literature supporting the testing at issue. Moreover, the testing at issue is not approved by the U.S. Food and Drug Administration nor supported by national guidelines. Therefore, the Colon Sentry test performed was not likely to be more beneficial for treatment of the patients medical condition than standard therapy such as a colonoscopy. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Two reviewers are board certified in medical oncology and are actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Upheld

This case concerns a 37-year-old male patient who is seeking reimbursement for a CT scan of the chest he underwent in June 2005. The Health Plan has denied this request because it has determined the CT scan was not medically necessary.The Health Plans denial should be upheld. A review of the information provided demonstrates the patient has a history of obesity, reactive airway disease, and hiatal hernia  status post Nissen fundoplication in May 2005. The patient underwent a chest CT scan in June 2005 for evaluation of continued complaints of chest pressure. The patient had been previously evaluated by pulmonology and otolaryngology. He also underwent a stress test in December 2004, which was normal. The CT scan was normal with evidence of fatty liver infiltration.The information provided does not demonstrate a CT scan of the chest was medically necessary. The patient had been previously evaluated by pulmonary medicine and had a normal chest x-ray in December 2004. He was also evaluated by otolaryngology and had a negative stress test. A lung exam in June 2005 revealed no adventitious lung sounds with a forced cough. He also denied any history of chest trauma, hemoptysis or history or findings consistent with pulmonary embolism. In addition, there is no information suggesting an ongoing malignant process (nonsmoker, no history of weight loss, no night sweats, no adenopathy) or suspected inflammatory disease. Therefore, there was no evidence of the need for a CT scan.Based upon the information set forth above, I have determined the CT scan at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested prescription medication Qualaquin for treatment of leg cramps.  Findings:  The physician reviewer found that the use of Qualaquin for the treatment of nocturnal leg cramps is not clinically appropriate nor is it   consistent with that definition. The FDA has specifically stated this drug should not be prescribed for leg cramps because of its side effects. The patient has documented heart disease and Qualaquin is known to have a significant impact on the conduction system within the heart. Additionally, there is very limited evidence of the effectiveness of this drug in preventing leg cramps in the peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee requested authorization and coverage of orthognathic surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees malocclusion.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested chlordiazepoxide (Librium) 10 mg, three times per day for treatment of his anxiety and alcohol recovery. Findings:  The physician reviewer found that paroxetine (Paxil) is an efficacious and well-tolerated treatment for generalized anxiety disorder (Rickels and colleagues). Overall, the medical literature suggests that although Benzodiazepines, of which Librium is one, may offer short-term benefit in lessening anxiety symptoms but they are not considered appropriate for long-term treatment. In fact, some studies suggest that Librium is no more beneficial than placebo over the long-term. At this time, selective serotonin reuptake inhibitors (SSRIs), including Paxil, are recognized as the pharmacologic treatment of choice for generalized anxiety disorder (GAD). It should be noted that this patient has not completed a reasonable trial of Paxil, Buspar, or Effexor, as more than one week is generally required in order for a patient to glean benefits. All told, there is inadequate medical justification for continued use of Librium to treat this patients GAD.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 5-year-11-month-old female has requested individual speech therapy, at a frequency of 1 session per week for 60 minutes per session for treatment of her autism.  Findings:  The physician reviewer found that the medical literature supports speech therapy in the autistic population. The report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Although the patients clinical presentation and the available data in the peer-reviewed medical literature demonstrate that speech therapy is medically necessary in this patient with autism, the underlying concern is whether 60 minutes per week of individual speech therapy is medically indicated over 30 minutes per week in this patient. While the medical literature demonstrates that the total hours of speech therapy received over the entire course of the patients treatment is significant, there is no literature supporting that speech therapy received in increments of 60 minutes per week is more effective than speech therapy received in increments of 30 minutes per week. It has not been established that a weekly 60-minute session results in better clinical outcomes in this patient population compared to a weekly 30-minute session. Rather, it is the overall duration of therapy (i.e., the total length of time the individual receives therapy) that is likely to affect outcomes in this setting. Thus, there is insufficient evidence to support the conclusion that 60 minutes per week of speech therapy is medically necessary over the proposed 30 minutes per week of speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 56-year-old female enrollee has requested authorization and coverage for Mavyret. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. These recommendations apply regardless of fibrosis stage. The guidelines cite data showing reduced survival with delayed treatment  For these reasons, the requested treatment with Mavyret is supported as 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested Avita 0.025% gel for the treatment of his lentigo. Findings:  The physician reviewer found that lentigo consists of benign lesions that do not cause a functional deficit. These lesions do not pose a risk for skin cancer. The treatment of such lesions is generally considered cosmetic, as its purpose is to improve appearance. Based on the clinical information provided, there is no medical indication for Avita gel in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female who is requesting coverage for the medication Actiq for severe axial neck pain due to minimal degenerative cervical spine arthritis and a small left local disc protrusion at C5-6. The Health Plan has denied coverage for Actiq on the basis that it is not medically necessary for the patients chronic pain.The Health Plans denial is correct. Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of chronic neck pain secondary to cervical spine disease. The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care. Therefore, I have determined the medication at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the rupture of membranes testing. As noted in the American College of Obstetricians and Gynecologists (ACOG) practice bulletin, most cases of premature rupture of membranes can be diagnosed on the basis of the patients history and physical examination. Specifically, sterile speculum examination provides an opportunity to inspect for cervicitis and umbilical cord prolapse or fetal prolapse, assess cervical dilatation and effacement, and obtain cultures as appropriate. Further, the diagnosis of membrane rupture typically is confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid, which is identified under microscopic evaluation. Given the false-positive test results with test kits evaluating patients for premature rupture of membranes, the rupture of membranes testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the rupture of membranes testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the rupture of membranes testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tofacitinib (Xeljanz) . The submitted documentation supports the medical necessity of the requested medication. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of which includes eyebrows, eyelashes and facial hair. Other autoimmune diseases are also linked. Treatment is challenging and aims at the regrowth (reconstruction) of hair. Although not life threatening or painful, its onset and erratic nature disturbs the lives of many.   Therefore, the use of tofacitinib (Xeljanz)  is scientifically justifiable for standard treatment resistant cases like this, and it is supported by medical literature and studies. Accordingly, under the present circumstances, tofacitinib (Xeljanz)  is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female has requested approval for a PET scan for evaluation of her Hodgkins disease.   Findings:  Two physician reviewers found that the patient was diagnosed with Hodgkins disease twenty-three years ago.  She was treated with chemotherapy.  Three years ago, a PET/CT scan showed no hypermetabolic activity.  Four months ago, the medical records noted weight loss, fatigue, and a slightly elevated IgM.  The current National Comprehensive Cancer Network guidelines do not advocate the use of PET scanning as a routine monitoring tool.  However, the current medical evidence supports the diagnostic procedure at issue in this clinical setting.  This patient presented with systemic complaints, including weight loss and fatigue.  Additionally, the medical records noted an elevated IgM.  In this patients case, further imaging evaluation is indicated.  The requested PET scan is likely to be superior over other available imaging modalities for the detection of possible recurrence.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion. Findings:  The physician reviewer found that  Evidence based medical guidelines support lumbar spine fusion for isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Wang and colleagues noted that lumbar fusion may be appropriate for patients with degenerative disc disease and disc herniations with radiculopathy when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. A study concluded that patients presenting with stenosis associated with a spondylolisthesis will often describe signs and symptoms consistent with neurogenic claudication, radiculopathy, and/or low back pain. The primary objective of surgery, when deemed appropriate, is to decompress the neural elements. As a result of the decompression, the instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is indicated to stabilize the spine and prevent delayed deterioration. Lumbar fusion is also supported in the setting of wide decompression with anticipated intraoperative instability. This patient presents with persistent worsening low back pain radiating into both lower extremities in an L5 distribution, worse on the right. Significant functional difficulty is documented in his ability to perform activities of daily living. In addition, the patients signs and symptoms are consistent with imaging evidence of spondylolisthesis at L5-S1 with foraminal stenosis and nerve root compromise. Moreover, there is electrodiagnostic evidence of chronic L5-S1 radiculopathies and radiographic evidence of spondylolisthesis at L5-S1 with instability documented on flexion/extension views. The provider noted the need for wide decompression to achieve adequate nerve root decompression which would result in intraoperative instability and necessitate fusion. For these reasons, the requested lumbar spinal fusion is considered medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery 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 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

A 47-year-old female enrollee has requested right ankle platelet rich plasma (PRP) tissue grafting for treatment of her right ankle pain.  Findings:  Three physician reviewers found that according to an article in the American Academy of Orthopaedic Surgeons (AAOS), the literature on the clinical use of PRP suggests that considerable variability exists in its effectiveness, even in the same clinical setting. Available data indicates that PRP may be valuable in enhancing soft tissue repair and in wound healing. However, the clinical role of PRP in bone repair remains controversial. Delos and colleagues reported that there are no definite indications for the use of PRP. In the absence of scientific data demonstrating the safety and effectiveness of PRP for treatment of painful ankle conditions, the PRP tissue grafting was not likely to provide this patient with an improved health outcome when compared to standard available alternatives.