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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 12 sessions of physical therapy per month.Findings:  The physician reviewer found that although a multidisciplinary approach to spine pain including physical therapy may be beneficial, the goal of physical therapy is to transition patients to an independent home exercise program without continued dependence on supervised therapy. The additional requested therapy is not accepted as specific and effective therapy for this patients condition. The documentation does not indicate that prior extensive physical therapy has resulted in significant objective increase in overall function. The services at this point do not need to be under the supervision of a therapist. The patient has had extensive prior physical therapy and should be well versed in a home exercise program. The expected rehabilitation potential is not significant in relation to the extent and duration of the physical therapy services requested. The specialized skill of a qualified therapist is not required to establish, design or deliver a maintenance program to maintain the patients current condition or to slow further deterioration. For these reasons, the requested 12 sessions of physical therapy per month are not medically necessary for treatment of this patients medical conditionFinal 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested a PET scan for an evaluation of his renal carcinoma and melanoma. Findings:  Three physician reviewers found that the use of F-18-FDG PET scan in this clinical setting is recognized as in accordance with generally accepted medical standards of practice. It is safe and effective and provides high sensitivity for assisting in proper treatment decisions. The clinical utility of PET scan in these circumstances is well-established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female has requested anterior cervical total disc arthroplasty with ProDisc-C cervical artificial disc for treatment of her cervical spondylosis and carpel tunnel syndrome.  Findings:  Three physician reviewers found that the patient is status post anterior cervical discectomy and fusion (ACDF) at C5-6 and sustained a motor vehicle accident. The patient indicates that since the accident, she has been experiencing neck pain and weakness of her hands as well as numbness of fingers of right hand that awaken her at night. She can do most of her activities. Her examination showed normal motor function and decreased sensation at C5 and C5-6 with normal reflexes. A magnetic resonance imaging (MRI) by radiologist report notes demonstrate a solid instrumented ACDF at C5-6 and mild canal stenosis at C3-4 and C4-5. She has also been diagnosed with carpal tunnel syndrome. Her surgeon noted the presence of severe stenosis C3-4 and C4-5.  This patient has chronic neck pain and carpal tunnel syndrome. She has no symptoms or signs of radiculopathy or myelopathy (Polston). Her pain generator in the neck has not been established. According to the Food and Drug Administration (FDA), having undergone a previous ACDF is a contraindication for total disc replacement. Similarly, the use of a hybrid construct with a combined ACDF and total disc replacement is not consistent with the FDA approved uses of ProDisc-C. Moreover, the FDA has required a post approval study to determine the long-term safety and effectiveness of ProDisc-C. This study is still underway and has not been reported. There are some promising studies on use of ProDisc-C, but these are small and short-term studies (Delamarter, et al). Thus, the requested surgery is not likely to provide this patient with greater benefit than standard modalities for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee requested authorization and coverage of continued inpatient services for the treatment of bi-polar disorder.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested 12 weeks of Harvoni 90-400 mg tablets for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  The guidelines note that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks.  These 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.  The current guidelines cite data showing reduced survival with delayed treatment.  All told, the requested medication regimen of 12 weeks of Harvoni 90-400 mg tablets is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision DX gene testing for evaluation of the enrollees melanoma. Findings: All three physician reviewers found that there is a lack of definitive data regarding the use of Decision DX gene testing for risk classification in patients with cutaneous melanoma.  This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested 3D-conformal therapy and Cyberknife stereotactic radiotherapy boost concurrent with capecitabine for treatment of her recurrent cholangiocarcinoma.  Findings:  Two physician reviewers found that utilization of image guided radiation therapy via Cyberknife has scientific merit.  Historically, patients with Klatskins disease have been treated in multiple approaches that attempt to deliver higher doses of radiation therapy primarily to the tumor while minimizing excess dose to critical surrounding tissue. Current technology today using image guided radiation therapy approach as a boost may not be the national standard of care, but the reason for this is that this technology is still relatively new. Given that Klatskins tumor is relatively rare, it is not possible to have large published series utilizing image guided radiation therapy. In fact, there is no evidence of any randomized study, published result on the appropriate treatment of Klatskins tumor/recurrences. Although data regarding the use of 3D conformal therapy and Cyberknife stereotactic radiotherapy with capecitabine in this particular setting is lacking, the beneficial aspects of the proposed therapy allow for delivery of radiation in a higher dose to the tumor bed, thus minimizing excess dose to the normal surrounding tissue.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year and ten-month-old female enrollee has requested for a speech evaluation and speech therapy for treatment of the enrollees expressive language impairment. Findings:  The physician reviewer found that documentation does not support the need of a speech evaluation and speech therapy for this patients isolated expressive language delay. The relevant medical literature does not contain convincing evidence to support the medical necessity of speech evaluation/therapy in a patient such as this patient. This patients physician has repeatedly documented that the patient has good motor skills, great comprehension and bilingual exposure. There is no evidence demonstrating the presence of any deficits other than an isolated expressive language delay which is likely to resolve at the patient matures.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an insulin pump for treatment of the enrollee's diabetes with servere hypoglycemia. Findings:  Three physician reviewers found that studies have shown that insulin pump therapy promotes tighter control of blood glucose levels and greater reduction of hemoglobin A1C, thereby reducing the chance of long-term complications associated with diabetes (Millstein, et al). Although this patients hemoglobin A1C is at or near goal, he continues to experience a high degree of glycemic variability, with frequent episodes of both hyperglycemia and hypoglycemia. Glycemic variability has been demonstrated to be associated with micro- and macrovascular complications and mortality independently of the hemoglobin A1C level (Gorst, et al). By using an insulin pump, this patient will likely be able to maintain an excellent hemoglobin A1C level while minimizing his variability, thereby lowering his risk of complications. Accordingly, the requested insulin pump is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for the treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the physician reviewer found 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Zepatier 50-100 mg tablets is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for staged excision of foreign body fat necrosis with antibiotic washout, debridement, and flap reconstruction of the hip area, legs, and gluteus maximus. The records document that this patient underwent buttock augmentation with injectable silicone or other substance at a non-medical facility after a previous gluteal augmentation with fat injection. The injected material is settling and causing deformity as well as tender and painful nodules. The patient presents with complaints of tender nodules and product migration to hip and groin folds with increased pain in buttocks, hips, and groin. The patient complains of numbness and tingling down legs, and intermittently feels unable to walk or feel the legs. A photograph received for review shows some skin darkening without evidence of induration or peau dorange. On review of the available documentation, it is not possible to remove the foreign material without excising a large amount of skin and muscle, with a result that will likely cause disfigurement and disability. Montrief and colleagues reported that, In the subset of patients presenting with silicone injection-based cosmetic buttock enhancement, special attention must be paid to local collections, as foreign material is present in affected tissue. In addition to hematomas and seromas, these patients may have a foreign body reaction with granuloma formation. Medical treatment as recommended by Kassamali and colleagues includes systemic steroids, hydroxychloroquine, and tetracyclines as first-line agents for silicone granulomas from injectable silicone, followed by tumor necrosis factor-alpha inhibitors for refractory disease. Based on the current medical literature, the requested staged excision of foreign body fat necrosis with antibiotic washout, debridement, and flap reconstruction of the patients hip area, legs, and gluteus maximus is contraindicated and 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

The parent of a male enrollee requested Pediasure for treatment of the enrollees food aversion.  Findings:  The physician reviewer found that the patient has food aversion related to his underlying autism spectrum disorder, exacerbated by intercurrent illness. In children with autism, food refusal may result in severe nutritional deficiency. Thus, supplementation with enteral formula is medically necessary to prevent essential vitamin and mineral deficiencies. In this case, vanilla Pediasure both satisfied the patients taste and allows for appropriate nutritional supplementation. Based on the medical literature cited above and the documentation submitted for review, the request for Pediasure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy, proton beam radiation therapy, and conformal radiation therapy for prostate cancer. In the comparison between intensity modulated radiation therapy and proton beam radiation therapy, intensity modulated radiation therapy patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between intensity modulated radiation therapy and proton beam radiation therapy. A position statement released by the American Society of Radiation Oncology (ASTRO) in 2013 stated, At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. The comparison plan between the photon and proton plans demonstrated no clinical benefit with the proton dosimetry. Therefore, proton beam radiation therapy was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 radiation oncology 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

This case involves a 55-year-old female who has requested authorization and coverage for breast prostheses replacement. The health plan has denied this request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees medical condition.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 considered cosmetic and is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a week long partial hospitalization intensive family eating disorder program. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for a week long partial hospitalization intensive family eating disorder program is not medically necessary for treatment of the patients medical condition. According to a study Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. Another study indicated that outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for treatment of anorexia nervosa. In regards to the appropriate levels of care for anorexia nervosa, a further study  recommend treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. In this case, the records submitted for review do not indicate that the patient has had intensive treatment for anorexia. The patients medical status is intact and the patient appears psychiatrically stable. The patient has recently lost weight and denies any history of purging. The patient had some minor laboratory abnormalities that could be addressed on an outpatient basis. The patient could be safely and adequately treated on an intensive outpatient basis. For the reasons provided, the requested services are not medically necessary for treatment of the patients anorexia nervosa, restricting type.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 psychiatry with sub-specialty certification in child and adolescent 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.