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

A 46-year-old female enrollee has requested coverage for revision of Roux-en-Y gastric bypass for treatment of her obesity.  Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of the requested procedure.  This patient has regained weight following Roux-en-Y gastric bypass.  She has an associated comorbidity of sleep apnea.  Although a reference to type II diabetes mellitus was made by her provider, the submitted laboratory data does not support this diagnosis.  An upper gastrointestinal study did not demonstrate any causes of failure of her prior gastric bypass surgery.  This patient does not meet the criteria for revision of prior gastric bypass surgery.  Although her body mass index was 35.69, she lacks associated comorbidities to support the requested procedure.  Additionally, there is insufficient documentation demonstrating that the patient has resumed medically supervised dietary interventions.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee requested authorization and coverage of a consultation for possible bilateral reduction mammoplasty. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation of the enrollees pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Ensure Complete Liquid. She has a history of bipolar disorder, anxiety, fibromyalgia, chronic bronchitis, obstructive sleep apnea, gastritis, gastroesophageal reflux disease (GERD), peptic ulcer, morbid obesity, and irritable bowel syndrome (IBS). She has a long history of gastrointestinal symptoms and has been taking Ensure Liquid. She was seen by her physician for diarrhea and stool studies were ordered for gastroenteritis. Her physician noted multiple Emergency Department (ED) visits in the last few weeks for ongoing diarrhea and nausea. Her abdomen was soft, and distended with hyperactive bowel signs, and diffuse tenderness to palpation. She reported she was drinking Ensure. A computed tomography (CT) scan indicates the patient had constipation; likely due to polypharmacy. She was seen in the ED again for abdominal cramping and diarrhea. Toradol, Imodium, Zofran, and Tylenol were prescribed. At a follow-up visit, she indicated she had nausea and could not eat any solids. Her body mass index (BMI) was 30.84. She requested an Ensure refill prescription, which the physician declined as she had been witnessed eating a sandwich without difficulty. The medical literature discusses adult body mass index (BMI). A normal BMI is 18.5  24.9. A BMI over 30 is considered obese. This patient had a BMI over 30. With this BMI, additional caloric supplementation is not required. There is insufficient evidence in the medical record of history of severe weight loss or malnutrition in this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for one hour, two times per week for treatment of the enrollees moderate expressive language impairment.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, 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 very seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties. The authors noted that while most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  This patient has moderate to severe expressive language delay, as well as lesser delays in receptive language and play. These deficits are significantly impairing his ability to communicate effectively and function socially. He has shown progress with weekly therapy to date, and continued twice weekly therapy would facilitate optimal speech and language development. All told, speech therapy for one hour, two times per week, is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast Botox injections performed. In the peer-reviewed medical literature, it was reported that patients who were injected with Botox in the pectoral muscles in the time between mastectomy and tissue expander placement reported less postoperative pain and used fewer narcotics in the first 24 hours after surgery and in the final expansion period than patients who did not receive the agent. Botox is an appropriate treatment for post-mastectomy breast reconstruction in this clinical setting. All told, the breast Botox injections performed were likely to be more beneficial for treatment of the patients condition than any available standard therapy.One reviewer found that the breast Botox injections performed were not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service 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 overturned.Credentials/Qualifications:  One reviewer is board certified in plastic surgery and is actively practicing. One Reviewer is board certified in plastic surgery and is actively practicing.  One Reviewer is board certified in plastic surgery 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: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested Orthovisc injections for treatment of her arthritis related knee pain. Findings:  Three physician reviewers found that the evidence supporting the use of viscosupplementation in the treatment of osteoarthritis is limited. A recent Agency for Healthcare Research and Quality (AHRQ) guideline does not provide support for viscosupplementation use. Additionally, there is limited evidence available in the peer-reviewed medical literature demonstrating the effectiveness of multiple series of viscosupplement injections. Other available treatments for osteoarthritis have been studied in the peer-reviewed medical literature and have been found to be safe and efficacious. At this time, there is inadequate scientific evidence demonstrating that the requested medication is likely to be more beneficial for treatment of the patients medical condition than available standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee requested authorization and coverage for a gastric bypass consultation. The health plan has denied this request indicating that the requested consultation is not medically necessary for treatment of the enrollees co-morbid conditions of type II diabetes mellitus, asthma, and degenerative joint disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested consultation is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old male who is HIV-infected and is being treated with appropriate anti-HIV therapy with good virological result. He has requested authorization and coverage for recombinant growth hormone (Serostim) for management of AIDs related wasting and weight loss. He reports that at 188 pounds he is more than 10% below his ideal weight of 220 pounds. He also states that his records include documentation of a normal serum testosterone while on testosterone therapy. There is a level of 125 ng/dL (low) in December 2005, and elevated levels in April and June 2005.At issue is whether Serostim is medically necessary for treatment of the patients medical condition.The patient does not meet medical necessity criteria for use of recombinant growth hormone. Based on the information provided, it appears the ideal body weight for a male who is 70 tall with a large frame is 160 to 193 pounds. In addition, the submitted materials include adequate documentation of normal serum testosterone while on replacement. Though the records do not document which anabolic agent was being used, there is a statement from the patients internist indicating that he was on nandrolone. Furthermore, there is no documentation in the submitted records of a lean body mass below 40%.If one assumes the patient was continually on testosterone replacement from April 2005 through August 2005, his weight has fluctuated only by about 5%. No information has been provided regarding the patients diet and there is no reason to believe the weight loss represents failure of testosterone therapy. Furthermore, a recent article by Storer, et. al. demonstrates that recombinant growth hormone and nandrolone are of equal efficacy in the management of AIDs-associated weight loss.The criteria set forth by the Health Plan for authorization of Serostim are medically appropriate and consistent with widely accepted recommendations. Since the submitted evidence demonstrates the patient does not meet these criteria, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for the Oncotype DX Genomic Prostate Score test for prostate cancer. The biopsy report showed adenocarcinoma, acinar type with a Gleason score of 6 (3+3) and a grade group of 1. The enrollees Genomic Prostate Score (GPS) score was 24, which denotes very low risk, and his prostate specific antigen (PSA) level was 7.1 ng/mL. The enrollees physician ordered the test to identify his specific risk of aggressive prostate cancer in order to make a more informed decision between active surveillance and immediate intervention. His physician indicates the GPS can identify those who need immediate surgery or radiation therapy versus those who can confidently choose active surveillance. The physician spoke with the enrollee specifically about the option of active surveillance and the enrollee understood it was a treatment option best suited for people with very low and low risk disease.  The enrollee underwent the recommended testing and was noted to be considered a very low risk. The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score indicates more favorable biology and less aggressive disease. Guidelines for prostate cancer indicate several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. However, there is limited data on clinical outcomes to support routine use of Oncotype DX. Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. A guideline on active surveillance of prostate cancer indicates use of ancillary tests beyond digital rectal exam, prostate specific antigen, and biopsy to improve enrollee selection or as part of monitoring in an active surveillance regimen remains investigational. Peer-reviewed studies do not show this test can help to know whether the cancer will return or change treatment decisions and improve subsequent outcomes. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology 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 16-year-old male enrollee has requested right and left bunionectomies and double osteotomy for the treatment of the enrollees pain due to pes planus.  Findings:  The physician reviewer found that bunion deformities are painful since the malposition of the first metacarpophalangeal (MPJ) causes joint tenderness and the boney protrusion of the medial aspect of the first metatarsal head causes extensive pressure and pain in shoe gear. The only way to correct a malpositioned first ray (first metatarsal, first proximal and distal phalanx), is with surgery. It is documented that conservative care has failed to alleviate this patients bunion pain, therefore surgery is warranted.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested continued intravenous immunoglobulin (IVIG) therapy for treatment of his muscle weakness. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  This patient has had progressive weakness, with examination and test results showing lower motor neuron abnormalities.  The patient has been diagnosed with possible multifocal motor neuropathy, with amyotrophic lateral sclerosis without upper motor neuron features considered more likely.  Per the current medical literature, the preferred therapy for multifocal motor neuropathy can include IVIG and steroids, which provide short-term benefit.  While the diagnosis is uncertain in this case, a continued therapeutic trial of IVIG is medically necessary.  Multifocal motor neuropathy may respond with repeated treatments with IVIG.  All told, continued IVIG therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a stress echocardiogram.The submitted documentation supports that the requested services are medically necessary. In this case, the patient has increased coronary risk (hypertension, diabetes, and a family history of premature coronary disease) and symptoms that are concerning for coronary ischemia. The pretest likelihood of obstructive coronary disease in this circumstance is at least intermediate, if not high, such that a stress echocardiogram or nuclear stress test with increased sensitivity and increased specificity compared to treadmill electrocardiography is desirable, even with a normal baseline electrocardiogram. Stress echocardiography is appropriate in this setting and is consistent with appropriateness criteria endorsed by several national organizations. Furthermore, the patient also presents with dyspnea of uncertain cause, and in this setting some evaluation of left ventricular function is appropriate to rule out cardiomyopathy as a cause of dyspnea. Under these circumstances, a stress echocardiogram would simultaneously evaluate both ischemia and left ventricular function. Accordingly, a stress echocardiogram is medically necessary for treatment of the patients medical condition.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 internal medicine, with subspecialty certification in cardiovascular 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cabometyx 60 mg for treatment of the enrollees metastatic gastrointestinal stromal tumor. Findings:  The physician reviewers found that Cabometyx is an oral inhibitor of tyrosine kinases, including MET, VEGFR, and AXL. Cabometyx has been approved for use in renal cancer and medullary thyroid cancer. A genetic analysis reveals that this patients cancer cells have mutations in KIT exons 11 and 17. According to the genetic analysis, the mutation in exon 17 suggests sensitivity to tyrosine kinases, but this is not very specific as to Cabometyx sensitivity. There is a lack of data suggesting sensitivity of GIST to this drug. The medical evidence does not support the requested medication in this clinical setting. All told, Cabometyx 60 mg is not likely to be superior over other available treatment options. Final Result: Two of three reviewers determined that the requested medication is 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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 magnetic resonance imaging (MRI) of the lumbar spine (CPT 72148).The American College of Radiology (ACR) appropriateness criteria indicates that for patients with subacute or chronic low back pain with or without radiculopathy who are candidates for surgery or intervention, a non-contrast MRI is usually appropriate. Additionally, the American Society of Neuroradiology (ASNR) practice parameters for MRI of the adult spine states, MRI provides a precise representation of the anatomy and the degenerative conditions of the disc, spinal canal, discovertebral complex, and facet joints that will promote accurate diagnosis of degenerative disc disease and influence therapeutic decision making. It is well established as the modality of choice for evaluating degenerative disease of the spine.In this case, the patient has had multiple plain x-rays. The patient has also undergone conservative management. While conservative management may be useful, after an interval of three years since the last MRI, it is reasonable to obtain another MRI study. There are several entities that generally do not respond to conservative management, such as a bony stenosis. In this patient, since further interventions are being contemplated, a repeat MRI study is medically appropriate. Therefore, MRI of the lumbar spine (CPT 72148) is medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Overturned

A 56-year-old female enrollee has requested magnetic resonance imaging (MRI) of the cervical spine for evaluation of her cervical pain with radiculopathy down the right arm.  Findings:  The physician reviewer found that while there was no clinical evaluation documented, the patient exhibited symptoms at that visit which would support an indication for MRI of the cervical spine per the National Imaging Associates (NIA) clinical guidelines. Specifically, the patient demonstrated decreased upper extremity reflexes and hypersensitivity of the right upper extremity as well as pain distribution in the C7 root distribution. These abnormal neurological findings qualify for MRI of the cervical spine based upon the information provided. Thus, the requested MRI of the cervical spine is medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female has requested residential treatment center (RTC) services for treatment of her behavioral health issues.    Findings:  The physician reviewer found that based on review of the available records, this patient was admitted to RTC level of care primarily because she had run away from home and was considered a flight risk. However, she was already in the juvenile system and there were legal constraints placed upon her. The records indicate that she had little previous substance abuse treatment for her daily use of cannabis. She refused all medications to treat her ADHD, mood and anxiety, and only accepted medication to help her sleep. The milieu notes indicate that she has not exhibited any serious behavior problems, such as threatening to run away or hurt herself or others. Her main problems in the milieu were arguing when told to do something and becoming upset over small matters. Although the treatment team states that she was at high risk because of her previous runaway behavior and suicide attempt, there is no evidence that she contemplated escaping from her program. All told, the RTC level of care services provided from the date at issue and forward are not supported as medically necessary for treatment of this patients medical condition.